<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:59:54 PM


Document Has Been Signed on 08/02/2024 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:JILL TUCKERFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 115DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Raul Pereira TIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/02/24, Licensing Program Analysts (LPA), Wendy Gibbs, Deborah Lee, and Yolanda Rosser, conducted an unannounced visit to the facility listed above. LPA’s met with Assistant Executive Director, Cecille Bernabe, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. Delayed egress approved for memory care and transitional units.

Physical Plant/Structure The facility consists of two buildings, one building is designated for Assisted Living and Memory Care residents and consists of two (2) floors and the other building consists of Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units’ rooms, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business office, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room and four (4) outside shaded patio with table and sufficient chairs and putting green. LPAs did not observe any bodies of water on the premises. LPAs observed all walkways and passages around the facility to be clean, clear, and free of obstructions, debris, and hazards.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident Rooms During the facility tour, LPAs inspected twelve (12) resident apartments and observed them to be clean and in good repair. The resident apartments inspected were 102, 106, 206, 219, 214, 216, 224, 232, 117, 104(M), 210(M), and 308(M). Resident’s apartments are furnished with their personal furniture. LPAs observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPAs observed beds to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the resident, but the facility does have a storage room with linens, and blankets incase a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit.
Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPAs observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPAs observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for resident use. LPAs observed the multipurpose/activity room to have tables and ample chairs. LPAs observed an ample supply of arts and craft supplies available for resident use. The activity schedule was posted outside the door. The dining room had multiple tables and chairs to accommodate residents. LPA’s observed snacks, and drinks available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms and hallways were observed with ample lighting. LPAs observed all walkways and hallways to be clean, clear, and free of obstructions and hazards.
Kitchen LPAs inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPAs observed all appliance to be in good working repair. LPAs observed
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
an ample supply of cookware, dishware, and cutleries in good repair. LPAs observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPAs reviewed the temperature logs for the freezer and the refrigerator. LPAs observed the monthly menus posted in the dining room and at the entrance of the dining room. LPAs observed all cleaning supplies secured in a locked storage room and are inaccessible to residents.
Safety LPAs observed multiple fully charged fire extinguishers last serviced on 09/12/23. The last annual fire inspection was conducted on 10/10/23. LPAs observed smoke detectors and carbon monoxide detectors to be operational. LPAs received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E). The last Emergency Drill was conducted on 06/16/24. The facility does have a working landline telephone. LPAs observed all required posting throughout the facility. LPAs reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators.
Medications LPAs observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original container. LPAs reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten out of ten resident’s MARs and medications are consistent with properly documented records.
Files LPAs reviewed 12 resident files and found they contained the required documents. LPAs reviewed the Administrator and eight (8) staff files and found they contain the required documents, certification, and training. LPAs received and reviewed a copy of the facility’s Liability Insurance. During file review, LPAs observed the licensing fees are current.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Infection Control LPAs observed multiple hand sanitizing stations throughout the facility. LPAs observed an ample supply of hand soap and paper towels. LPAs observed required infection control signs posted throughout the facility. LPAs observed a 60-day supply of Personal Protective Equipment (PPE).

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

An exit interview was conducted with Business Office Manager, Raul Periera, and Assistant Executive Director, Cecile Bernabe, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4