198603118-9-9-2024-11-AS-EMAZ-D9TT6K-20241007142717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 09/06/2024
Date Signed: 09/09/2024 12:11:59 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
12/14/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20231214094359

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:	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Cecille Bernabe		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items
Staff did not document or report incidents to resident's authorized person
Staff did not provide activities for residents
Staff mismanage resident medication
Staff do not safeguard confidential information
Staff do not provide utensils for residents
Staff are unable to communicate with residents

INVESTIGATION FINDINGS:

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On 09/06/24, Licensing Program Analyst, Wendy Gibbs, conducted a subsequent visit to the facility listed above to deliver findings. LPA met with Assistant Executive Director/Memory Care Director, Cecille Bernabe, and Office Business Director, Raul Periera, and the purpose of today’s visit was explained the purpose of today’s visit.
During a subsequent visit conducted on 12/20/23 LPA interviewed staff (S1-S9) and residents (R2-R3), toured the facility, and received pertinent documents for the investigation. LPA reviewed and received copies of the following documents, staff roster, resident roster, resident Appraisal, Needs and Service Plans, Physician’s Report, Nurse/Staff Notes, Safeguard of property/valuables, incident reports, Centrally Stored Medications, Medication Administration Record (MAR), Weight Log, Activity Schedule, Menu, Laundry Schedule, Cleaning Schedule, and staff Training Logs.
On an additional subsequent visit conducted on 02/09/24, Licensing Program Analysts (LPA), Wendy Gibbs and Alfonso Iniguez met with Executive Director, Paul Gozon. During the visit LPAs toured the (1A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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

LIC9099 (FAS) - (06/04)

Page: 10 of 10

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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facility, interviewed Residents (R1-R6), interviewed Staff (S6-S9), and received documents pertinent to the investigation. The documents reviewed and received include Staff Roster, Resident Roster for Memory Care Unit, Staff Training Logs of 100 modules Dementia Care and 10 modules on Falls, Resident Admission Agreement, Physician Reports, Communication Logs, and Safeguard of Property.
During an additional subsequent visit conducted on 08/29/24, LPA met with Assistant Executive Director/Memory Care Director, Cecille Bernabe and Office Business Manager, Raul Pereira. During the visit, LPA toured the facility, interviewed Staff S2, and received documents pertinent to the investigation. The documents received and reviewed include Unusual Incident/ Injury Reports (SIR)s, Outside Agency Documentation, Skin Integrity Monitoring Form, Internal Occurrence report, and resident Hospital Discharge paperwork.
The investigation revealed the following:
Allegation: Staff did not safeguard resident’s personal items
The complaint allegation alleges resident’s personal items such as clothes and tooth brush have gone missing.
During the facility record review, LPA received and reviewed a copy of the Client/Resident Personal Property and Valuables (LIC621) for sis residents. LPA observed six (6) out of six (6) residents declined to fill out the form. During review of residents Admission Agreement, LPA observed in Appendix K Safeguard of Resident Property on page 2 states “the facility shall not be liable for items which have not been requested to be included in the inventory or for items which have

(2A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 11 of 16

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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been deleted from the inventory.”
During interviews with Staff S1-S8, were asked how the facility safeguards residents personal belongings, eight (8) out of eight (8) stated they encourage residents to keep personal belongings in their room and to lock their door when they leave their rooms.
During interviews with Residents R1-R6, were asked if they had any items go missing, six (6) out of six (6) stated they have had no items go missing.
Allegation: Staff did not document or report incidents to resident’s authorized person
The complaint allegation alleges the responsible person was not notified of residents falls or injuries.
During record review of Resident R1’s Progress Notes, LPA observed staff called the responsible party to inform them of incident’s that occurred on the following dates: 08/21/23, 09/20/23, 11/10/23, 12/14/23, 12/22/23, 12/29/23, and twice on 12/30/23. LPA observed messages were left on 12/29/23 and 12/30/23 until they were able to get in contact with the responsible party. LPA observed in the notes when they called a number for the responsible party, they kept getting a message stating the phone was waiting to connect, and the phone is unavailable. Additionally, LPA observed in the notes the staff left a message on an alternative phone number listed. In which, staff was informed by the responsible party that they were no longer using the number where they messages were left.
During interviews with Staff S1-S8, were asked if residents responsible party is

(3A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 12 of 16

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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notified if a resident has a fall or sustains an injury, eight (8) out of eight (8) stated the responsible party is notified of a residents fall, injury, or change of condition as soon as possible.
During interviews with Resident R1-R6, were asked if their responsible party is notified of any fall, injuries, or change of condition, six (6) out of six (6) stated their family is notified of falls and injuries.
Allegation: Staff did not provide activities for residents
The complaint allegation alleges staff do not provide activities for the residents.
During records review, LPA Iniguez observed copies facility activities calendar from October, November, and December 2023.
During a tour of the facility, LPA Gibbs and Iniguez observed activities being performed to the residents in care. In addition, posting of daily activities is available in the common areas accessible to residents in care.
During an interview with administrator (S#1) he stated that the facility offers activities for residents in care.
During interviews with residents (R#1-R#6) (6) out of (6) stated that the facility provides activities.
During an interview with facility staff (S#2-S#9) eight (8) out of eight (8) stated that the facility offers activities for residents in care, if they would like to participate.
Allegation: Staff mismanaged resident medication
The complaint allegation alleges that the Med Tech was unavailable when the family of a resident requested a PRN medication.
During records review, LPA Iniguez observed copies of memory care Med Tech medication training logs. In addition, LPA Iniguez observed staff received training
(4A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 13 of 16

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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concerning emergency events in their Relias modules.
During a tour of the facility, LPAs Gibbs and Iniguez observed Med Techs in the Towers main medication room on the first floor. LPAs reviewed six (6) residents’ medication and electronic Medication Administration Record (eMar) and observed six (6) out of six (6) residents eMAR’s and medication are consistent with properly documented records.
During an interview with administrator (S#1) he stated that the facility staff is trained regarding first aid assistance.
During interviews with residents (R#1-R#6) six (6) out of six (6) stated they receive their medication when prescribed and PRNs when needed.
During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated residents are given their medications as prescribed and follow procedure for PRN medications.
Allegation: Staff do not safeguard confidential information
The complaint allegation alleges that resident’s information and confidential information is not kept in a safe place.
During the facility tour, LPAs Gibbs and Iniguez observed resident’s medical files secured in the locked medication room. Additionally, during the tour, LPAs observed residents’ facility documents secured in the locked business office managers office.
During interviews with Staff S1-S8, were asked how they keep residents personal information safeguarded, eight (8) out of eight (8) stated personal files for the resident are locked in the medication room and the office. Additionally, eight (8) out of eight (8) stated they do not provide any information to any person other than the
(5A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 14 of 16

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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residents responsible party, physician, home health, or hospice representative.
During interviews with Residents R1-R6, were asked if the facility safeguards their personal information, six (6) out of six (6) stated the facility safeguards their information.
Allegation: Staff do not provide utensils for residents
The complaint allegation alleges that residents are given their meals without utensils and residents eat their food with their hands.
When LPA’s Iniguez and Gibbs arrived at the facility the residents were having breakfast and LPAs observed residents were provided with utensils. Additionally, LPA’s observed lunch being served to residents in the Tower and utensils were provided. During the facility tour, LPAs observed an ample supply of utensils in the kitchen.
During interviews with Staff S1-S8, were asked if residents are provided with utensils during meals and snack, eight (8) out of eight (8) stated residents are provided with utensils.
During interviews with Residents R1-R6, were asked if they are provided with utensils during meals, six (6) out of six (6) stated yes, they are provided with utensils for meals.
Allegation: Staff are unable to communicate with residents
The complaint allegation alleges that staff are unable to communicate with residents.
During records review, LPA Iniguez observed that facility staff have taken the following courses in Relias: Communication and People with Dementia, Cultural

(6A) 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 15 of 16

Control Number 11-AS-20231214094359

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: 09/06/2024

NARRATIVE

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competence, Ethical Considerations and The Aging Process. These courses emphasize the importance of communication.
During an interview with administrator (S#1) he stated that the facility staff is able to communicate with the residents. Also, (S#1) stated that the facility staff does not have problems understanding the residents in care.
During interviews with residents (R#1-R#6) (5) out of (6) stated that they are able to communicate with the facility staff and they do not have problems understanding what the facility staff says to them.
During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated that they are able to communicate with the residents in care and some of the ways they used are: reviewing resident’s records, taking their time to make sure residents understand them.

During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

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

An exit interview was conducted with Assistant Executive Director/Memory Care Director, Cecille Bernabe, and Office Business Director, Raul Periera, and a copy of this report was provided.

(7A)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

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