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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 11/18/2023
Date Signed: 11/18/2023 03:45:28 PM


Document Has Been Signed on 11/18/2023 03:45 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, 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: 119DATE:
11/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Paul Gozon-Executive DirectorTIME COMPLETED:
03:44 PM
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On 11/18/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Paul Gozon/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, of which (13) may be bedridden. Delayed egress approved for memory care and transitional units.

The facility is two building structures, 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 are a total of (54) Assisted Living units and (55) Memory Care units’ rooms, kitchen, TV room, multipurpose room, 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 patio with table and sufficient chairs and putting green. There's no body of water around the building. All outdoor and indoor passageways are free of obstruction.



LPA Iniguez toured the physical plant with Health Services Director. There were no bodies of water or obstructions on the premises. A total of (12) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #105, #106, #107, #217, #213, #214, #115(M),#104(M), #103(M), #107(M), #105(M) and #102(M); call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 11/18/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 9/6/23. Annual fire clearance performed on 9/30/2023. Working landline phones are available on-site. A review of (6) residents' service files, (6) staff personnel files were kept properly. (6) Medication Administration Records (MAR) were observed.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility.

Executive Director will email copy of liability insurance to LPA.

Technical Advice notes given to Executive Director

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D pages)


An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Executive Director/ Paul Gozon.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in staff not documenting when giving prescribed medications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Executive Director must ensure all staff who gives prescribed medications to resdients must do the proper documentation. As POC Executive Director will provide a re-training of staff and send proof to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 11/18/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in keeping cleaning agents away from memory care residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Executive director removed cleaning agent during LPA visit. In addition, as part of POC Executive director will ensure no other cleaning agents are in reach of memory care residents. As part of POC Executive Director will re-train care staff and family members regarding the importance of keeping cleaning solutions in a secure area. Executive director will sent proof of correction to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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