198603118-2-10-2024-11-AS-JHAD-D2GP5B-20240215100026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 02/10/2024
Date Signed: 02/10/2024 12:10:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220823144132

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	JILL TUCKER		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 118	DATE:	02/10/2024
		UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Kathryn O'Brien		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted in severe injury.

INVESTIGATION FINDINGS:

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On 02/10/24 Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Lifestyle Director (S4: Kathryn O'Brien). LPA conducted a risk assessment prior to entering the facility and observed COVID-19 protocol. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following:
An initial visit was conducted by LPA Jeremiah Randle on 08/24/22 with Executive Director/ Administrator (A1: Michele Johnson). LPA toured the facility and observed the facility to be in good condition. Residents were currently sitting in the common area engaged in social activities. Residents that were observed did not show signs of distress or abuse.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220823144132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 02/10/2024

NARRATIVE

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Currently there are 118 residents; of which, five (5) are non-ambulatory and sixteen (16) are receiving hospice care. LPA requested the following pertinent documents pertaining to the investigation: resident roster, staff roster, admission/memory care agreement (dated 08/04/22), power of attorney (effective 06/01/21), appraisal needs and services plan (08/04/22), physician report (08/02/22), level of care plan (dated 08/04/22), progress notes (from 08/18/22 – 08/26/22), private care agreement (dated 08/04/22), facility staff schedules (from 08/01/22 – 08/23/22), and incident report (dated 08/22/22). Due to the nature of the complaint, it was referred to the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD), Investigation Bureau (IB). Investigation Bureau (IB) accepted and assigned the full investigation to Investigator Heidy Bendana. The investigation included a review of medical records from Torrance Memorial Medical Center (dated 08/22/22); interviews with facility staff (A1, S1 – S3), residents (R1, R3, and R4), and witness (W1). IB Investigator Bendana did not interview Resident #2 (due to cognitive impairment) or Witness #2 (due to unavailability).

The investigation revealed the following:
Regarding Allegation #1: this investigation revealed based on Torrance Memorial Medical Center’s medical records that Resident #1 did not sustain a fracture resulting from an unwitnessed fall at the facility on 08/22/22 nor did the medical records for admission (dated 08/22/22) mention bruising or skin tears. A CT scan was conducted of the left hip with findings showing no acute fracture was identified. No definite fracture of the left femur was identified. CT was obtained to rule out acute fracture and all findings are consistent with an old injury. Prior to being admitted to the facility, Resident #1 went for a walk in their neighborhood and was found on the ground and transported to Torrance Memorial Medical Center ER for an unwitnessed fall on 07/17/22. Resident #1 complained of some left hip pain even though clinically suspicion of fracture/dislocation was low. X-ray of the left hip did not show acute abnormality. Resident #1 was discharged to Del Amo skilled-nursing facility on 07/19/22. On 08/10/22, Resident #1 was presented to the emergency department (ER) at Torrance Memorial Medical Center for evaluation of skin tears to the upper extremities after an unwitnessed fall from their bed at the skilled nursing facility.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220823144132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 02/10/2024

NARRATIVE

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Resident #1 accidentally slipped while getting out of bed and sustained skin tears to their upper extremities. Resident #1’s responsible person disclosed that Resident #1 has “sensitive” and “thin” skin which causes bruising and skin tears to occur easily with a longer healing period. Based on this investigation, Resident #1 was admitted to Clearwater at South Bay on 08/04/22, facility staff took preventative actions because of the unwitnessed fall incident on 08/22/22. Facility staff changed Resident #1’s bed, ordered an alarm that attached to the resident’s clothing to sound off when the resident got up, a sensor mat to alert caregivers when the resident gets up from their bed, caregiver rounds were more frequent at an hour time frame, and established a toileting routine which the resident is taken to the bathroom every two (2) hours. In addition, facility staff recommended and assisted in Resident #1 having a private caregiver (Witness #2) at night 02/07/24 (between 2100 hours to 0700 hours, seven days a week). During the day, Resident #1 is in the common area where the resident is under constant supervision.

Based on the evidence gathered, interviews conducted, and medical records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of Neglect/Lack of Supervision resulted in severe injury is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Lifestyle Director Kathryn O'Brien.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024

LIC9099 (FAS) - (06/04)

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