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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 12/23/2025
Date Signed: 12/23/2025 05:50:29 PM

Document Has Been Signed on 12/23/2025 05:50 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/
DIRECTOR:		PAUL GOZONFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 137CENSUS: 99DATE:
12/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Paul GozonTIME VISIT/
INSPECTION COMPLETED:
05:00 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 12/23/2025 at 8:31, Licensing Program Analysts (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Executive Director, Apolinario ‘Paul’ Gozon, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. The facility has been approved for delayed egress in the memory care and transitional units.
Physical Plant/Structure The facility is located in a commercial area. It consists of two buildings, one building is designated for Assisted Living and Memory Care residents and has two (2) floors. The additional building is for Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business offices, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room, and five (5) outside shaded patio areas with tables and chairs. LPA did not observe any bodies of water on the premises. LPA observed all walkways and passages outside the facility to be clean, clear, and free of obstructions, debris, and hazards.
Resident Rooms During the facility tour, LPA inspected ten (10) resident apartments and observed them to be clean and in good repair. The resident rooms inspected were rooms 105, 109, 206, 307, 310, 113, 120, 205, and 225. Resident’s apartments are furnished with their personal furniture. LPA observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPA observed beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the residents, but the facility does have a storage room with linens, and blankets in case a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 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: 12/23/2025
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
Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPA observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPA observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for residents’ use. LPA observed the multipurpose/activity room to have tables and ample chairs. LPA 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 observed snacks and drinks are available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms, walkways and hallways in the facility were observed with ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards.
Kitchen LPA inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPA observed all appliances to be in good working repair. LPA observed an ample supply of cookware, dishware, and cutlery in good repair. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPA reviewed the temperature logs for the freezer and the refrigerator. LPA 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 LPA observed multiple fully charged fire extinguishers last serviced on 10/20/25. The last annual fire inspection was conducted on 09/19/25. LPA observed smoke detectors and carbon monoxide detectors to be operational. LPA received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E) last updated on 01/16/2025. The last Emergency Drill was conducted on 10/16/25. The facility does have a working landline telephone. LPA observed all required posting throughout the facility. LPA reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators.
Medications LPA observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original containers. LPA reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten (10) out of ten (10) residents’ MARs and medications are consistent with properly documented records.
Files LPA reviewed ten (10) resident files and found they contained the required documents. LPA reviewed the Administrator and six (6) staff files and found they contained the required documents, clearance, certification, and training. LPA received and reviewed a copy of the Liability insurance through Acord valid till 11/11/2026. During file review, LPA observed the Licensing Fees are current.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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: 12/23/2025
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 a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4