198603118-7-31-2026-11-AS-EMAZ-DWQVKJ-20260807163025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 07/31/2026
Date Signed: 07/31/2026 05:13:45 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
06/10/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260610100831

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	PAUL GOZON		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 107	DATE:	07/31/2026
		UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Krista Solomon		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff gave expired medication to resident in care

INVESTIGATION FINDINGS:

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On 07/31/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Krista Solomon, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
During today's visit, LPA inspected the facility, reviewed ten (10) residents Centrally Stored Medications, interviewed Staff S1 and S7, and interviewed Residents R2-R12.
During the initial visit conducted on 06/17/2026, LPA interviewed Staff S2-S6 and received and reviewed pertinent documents to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Physician’s Orders, Medication Administration Record (MAR), Centrally stored medications, and Medication Sign-In and Medication Sign-Out.

The investigation consisted of the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260610100831

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: 07/31/2026

NARRATIVE

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Allegation: Staff gave expired medication to resident in care
The allegation alleges a resident was provided an expired medication.

During a medication review, LPA reviewed the Centrally Stored Medications for ten (10) residents and observed ten (10) out of ten (10) residents’ medications were not expired.

During record review, LPA received and reviewed R1’s Preplacement Appraisal Information (dated 04/29/2026) that lists Trazadone under medications taking. LPA observed on the Centrally Stored Medication & Destruction Records (dated 05/11/2026) for R1 did not list Trazadone. LPA received and reviewed the Physician Report and Admission Orders (dated 05/04/2026) and did not observe Trazadone listed on the Admission Orders. LPA observed on the Notes and Incidents Log, dated 05/14/2026, staff contacted R1'sPrimary Care Physician to request an order for Trazdone. LPA received and reviewed a Prescription slip date 05/15/2026 for Trazodone. LPA reviewed the eMAR for R1 and observed R1 received Trazodone from 05/16/2026 through 06/07/2026.
During interviews with Staff S1-S7, were asked if a resident has been given and expired medication, seven (7) out of seven (7) stated no, to their knowledge no resident has been given expired medication. Additionally, Staff S1-S7 were asked how often medications are checked if they are expired, seven (7) out of seven (7) a monthly audit is conducted to review all medications expiration date.
During interviews with Residents R2-R12, were asked if they have been given expired medication, eleven (11) out of eleven (11) stated no, they have not been given expired medication.

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 did or did not occur, therefore the allegation is unsubstantiated.

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

An exit interview was conducted with Rhonda Madrid, Sales Director, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC9099 (FAS) - (06/04)

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