198603118-3-19-2024-11-AS-EMAZ-D3LTXS-20240322150735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:55:53 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240314085546

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: 121	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Paul Gozon		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff do not store cleaning chemicals locked and inaccessible to residents in care

INVESTIGATION FINDINGS:

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On 03/19/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a complaint visit to the facility listed above. LPA met with Executive Director, Paul Gozon, and the purpose of today’s visit was explained.

During today’s visit LPA toured the facility, interviewed Staff (S1-S7), interviewed Residents (R1-R8), and received documents pertinent to the investigation. The documents received and reviewed include the Staff Roster, Resident Roster, Relias training logs, and in-service training logs.

The investigation revealed the following:
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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-20240314085546

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 03/19/2024

NARRATIVE

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Allegation: Facility staff do not store cleaning chemicals locked and inaccessible to resident in care.

It is alleged that in the memory care unit, cleaning products are left out on the counter or put in cabinet that is not secured and is accessible to residents.

During the facility tour, LPA and the Executive Director toured the full Memory Care Unit. LPA observed that on all three floors of the Memory Care Building, each kitchenette had a locked cabinet under the sink where cleaning supplies are stored. LPA observed that all cleaning products were inaccessible to residents. Staff opened cabinet and LPA observed the only cabinet with cleaning supplies in it was the locked cabinet under the sink. Additionally, LPA checked the laundry room on each floor, and observed they were secured and locked. LPA observed housekeeping cleaning rooms on the first floor of the Memory Care and observed the cleaning chemical supplies box was locked at all times. LPA observed when the housekeeper needed a different product, they unlocked the box, put away what they had, took out what they needed, and locked the box again. During interviews with staff (S1-S7), were asked if they have received training's regarding the storage of cleaning chemicals, seven (7) out of seven (7) stated they have received training through Relias and In-Services regarding the storage of cleaning chemical. Additionally, seven (7) out of seven (7) stated that when not in use cleaning products are secured in a locked cabinet under the sink and are inaccessible to residents. During interviews with Residents (R1-R8), were asked if they have observed cleaning chemicals left out on the counter at any time,

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240314085546

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 03/19/2024

NARRATIVE

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eight (8) out of eight (8) stated they have not seen any cleaning supplies left out and accessible. During record review, LPA reviewed training logs for seven (7) staff, LPA observed seven (7) out of
seven (7) had completed the Relias training regarding Chemical Safety. Additionally, LPA received and reviewed In-Service training logs, conducted on November 18, 2023 and March 7, 2024, regarding Chemical Safety and Maintenance of Supplies/Chemicals.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

During today's visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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