198603118-1-30-2025-11-AS-EMAZ-DGNSDA-20250514134645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 01/30/2025
Date Signed: 01/30/2025 12:54:08 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
10/16/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20241016160832

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:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Paul Gozon		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff have not provided authorized representative a copy of resident's file
Due to staff neglect, resident sustained a wound
Staff are double diapering resident
Staff left resident in soiled diapers

INVESTIGATION FINDINGS:

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On 01/30/2025, the department conducted a subsequent visit to the facility listed above to deliver findings for a complaint. The department met with Executive Director, Paul Gozon, and the purpose of the visit was explained.
During today’s visit, the department toured the facility and received additional documents. The documents received and reviewed are staffing notes for R1. During a subsequent visit conducted on 10/24/23, the Department inspected the facility, interviewed Staff S1-S12, interviewed Residents R3-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, staff Training Logs regarding ADL’s, Toileting/Incontinence, emails between S1, S2 and residents’ family, Resident’s Face Sheet, Physician’s Report, Consent Forms, Resident South Bay Health and Service Evaluation Service Plan, Power of Attorney, Centrally Stored Medications, Resident Intake Form, Admission Agreement, Outside Agency Documents, and Hospital Discharge Documents.

The investigation revealed the following:

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: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 11-AS-20241016160832

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: 01/30/2025

NARRATIVE

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Allegation: Staff have not provided authorized representative a copy of residents’ file.
The complaint allegation alleges that a resident’s authorized representative has requested a copy of the residents’ rental agreement and visitor logs and have not received them.
During a record review the Department received and reviewed Residents R1 and R2 Heath Information Release Authorization, dated 03/22/2023, that states Resident’s son or daughter are authorized to receive all medical records. Additionally, the department received and reviewed R1 and R2’s California Uniform Statutory Power of Attorney dated 10/23/2017, that allows the son and daughter to act as agents with the powers in California Probate Code Sections 4400-4465. The department received and reviewed a Durable Power of Attorney dated 07/23/2024 for R1 and R2 naming their daughter and son as appointed Power-in-Fact. Both documents give the daughter and son the authority to make decisions for their parents regarding finances and property.
During interviews with Staff S1-S12, were asked if a resident’s representative requested documents regarding their resident how long does it take to process their request, four (4) out of twelve (12) stated it could take 24-hours to a week to processes that request. Additionally, Eight (8) out of twelve (12) stated they are not sure how long it would take, and they would instruct the residents authorized representative to speak to S2 regarding the request. Additionally, S1 stated they sent all the documents to the daughter that were requested.
During interviews with Residents R3-R11, were asked if their family has requested documents from the facility and if they received the documents requested, five (5)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241016160832

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: 01/30/2025

NARRATIVE

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out of nine (9) stated their family got documents right away. Additionally, four (4) out of nine (9) stated they have not requested any documents from the facility.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Due to staff neglect, resident sustained a wound.

The complaint allegation alleges that a resident was observed with an abscess from an unknown cause.
During record review the department received and reviewed discharge paperwork from Torrance Memorial Hospital dated 08/15/2024. On 08/12/2024 R1 was admitted to Torrance Memorial Hospital and discharged on 08/15/2024, on the discharge paperwork the department did not observe any indication of an abscess. R1 returned to the facility with a private caregiver till they were transferred to a skilled nursing facility. On 08/18/2024, R1 was admitted to Berkley Post-Acute for physical therapy and occupational therapy. On 08/23/2024, R1 was prescribed Bactrim DS Tablet 800-160 MG for abscess on pubical area. The Transfer/Discharge Report from Berkley Post-Acute dated 08/26/2024 on diagnoses listed is “other specified dermatitis.” The discharge summary from Berkley Convalescent Hospital dated 08/26/2024 indicates R1 has a wound on the groin area. The facility provided a document for Outside Agency Documentation dated on 09/03/2024, AllCare Home Health conducted a visit for Wound Care on the groin. The department received and reviewed a prescription order, dated 08/28/2024, for Mupirocin, an ointment to be applied to an abscess for the groin.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20241016160832

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: 01/30/2025

NARRATIVE

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The department received and reviewed the electronic Medication Administration Record (eMAR) for R1 for the months on August and September 2024 that indicates the cream was applied three (3) times a day as prescribed.
During interviews with Staff S1-S12, were asked if any residents have sustained a wound due to neglect such as being left in soiled diaper for an extended period of time, or lack of hygiene care, twelve (12) out of twelve (12) stated no, they have no knowledge of a resident sustaining wounds due to neglect.
During interviews with Resident’s R3-R11, were asked if they have sustained a wound due to neglect, nine (9) out of nine (9) stated they have not sustained injuries due to neglect.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff are double diapering diapers.

The complaint allegation alleges that resident was placed in double diapers overnight.
During record review the department received and reviewed In-Service Training Log and material used in the training conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20241016160832

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: 01/30/2025

NARRATIVE

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12/01/2023. The policy stated, “incontinence products should be used, if appropriate, and the resident’s incontinence product should be changed as needed.”
During interviews with Staff S1-S12, were asked if residents are placed in double diapers, twelve (12) out of twelve (12) stated no residents are placed in double diapers.
Additionally, staff S1-S12 were asked if they have heard of a residents placed in double diapers, eleven (11) out of twelve (12) stated they have not heard that from a resident or a resident’s family. S2 stated R2’s daughter informed them that R2 was observed with double diapers on two (2) occasions. S2 stated it was addressed right away with the staff and an In-Service Training was conducted to ensure it did not happen again.
During interviews with Resident’s R3-R11, were asked if they have been placed in double diapers, nine (9) out of nine (9) stated they have not been placed in double diapers.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff left resident in soiled diapers.

The complaint allegation alleges that resident is left in soiled diapers.
During file review at the facility, the department received and reviewed a copy of the Care Partner Job Description that states care partners need to frequently check to

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20241016160832

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: 01/30/2025

NARRATIVE

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see if incontinent residents need changed. Additionally, the department received and reviewed In-Service Training Log and material used conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy states staff will “Initiate toileting at least every two (2) hours and prior to typical “pattern” time.
During an interview with the Administrator S1, was asked how often residents are assisted with incontinence, S1 stated residents are assisted every two (2) hours and some residents do require additional checks due to increased urine output from medications or fluid intake.
During interviews with Staff S2-S12, were asked how often incontinent residents are assisted with changing, eleven (11) out of eleven (11) stated residents are assisted with changing every 2 hours if not more.
During interviews with Residents R3-R11, were asked if they have been left in soiled diapers for an extended period of time, nine (9) out of nine (9) stated they have not been left in soiled diapers.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During today's visit the department 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: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

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