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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 10/23/2025
Date Signed: 10/23/2025 04:27:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251014124606
FACILITY NAME:CLEARWATER AT SOUTH BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:PAUL GOZONFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 101DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Paul Gozon - Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not properly follow reporting requirements
INVESTIGATION FINDINGS:
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On 10/23/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced initial complaint visit at the facility. LPA was met by staff one, Paul Gozon - Executive Director (S1) and the purpose of the visit was explained.

The investigation consisted of the following:
LPA requested and reviewed the following documents: Resident and staff roster (dated: 10/23/25), special incident reports of residents in care (dated: 09/01/25 through 10/01/25), hospice care notes (dated: 09/01/25 through 10/01/25) and pre-admission and admission appraisals as well as facility vitals. LPA interviewed seven (7) staff (S1-S7) and three (3) residents (R1-R3).


Report continues, please see LIC9099-C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2025 and conducted by Evaluator Mario Leon
COMPLAINT CONTROL NUMBER: 11-AS-20251014124606

FACILITY NAME:CLEARWATER AT SOUTH BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:PAUL GOZONFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 101DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Paul Gozon - Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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9
Staff has inadequate record keeping
INVESTIGATION FINDINGS:
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13
On 10/23/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced initial complaint visit at the facility. LPA was met by staff one, Paul Gozon - Executive Director (S1) and the purpose of the visit was explained.

The investigation consisted of the following:
LPA requested and reviewed the following documents: Resident and staff roster (dated: 10/23/25), special incident reports of residents in care (dated: 09/01/25 through 10/01/25), hospice care notes (dated: 09/01/25 through 10/01/25) and pre-admission and admission appraisals as well as facility vitals. LPA interviewed seven (7) staff (S1-S7) and three (3) residents (R1-R3).


Report continues, please see LIC9099-C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20251014124606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 10/23/2025
NARRATIVE
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The investigation revealed the following:
Regarding the allegation, "Staff has inadequate record keeping", it is being alleged that the facility does not include important information regarding an incident that has occurred to a resident in care. Interviews revealed the following: four (4) out of seven (7) staff have confirmed that a resident was observed, after a fall, on the right hand side of their body, while three (3) staff were not familiar how the resident was observed after this fall. Hospice notes were observed, which indicated that there were no abnormal vitals recorded on 09/16/25, 09/17/25 and 09/26/25. Notes from staff at the facility have been recorded during the time period of 04/11/25 through 10/04/25, no abnormalities of documentation has been observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20251014124606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 10/23/2025
NARRATIVE
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The investigation revealed the following:
Regarding the allegation, "Staff did not properly follow reporting requirements", it is being alleged that the facility has not submitted a special incident report (LIC624) within California's required timeline. Upon receiving the LIC624, lpa reviewed the dates recorded on the LIC624. Per title 22 regulation, a facility is to submit a written report within seven (7) days after the occurrence of an injury to any resident(s) in care. The injury took place on 09/15/25, leaving until 09/22/25 for the facility to submit LIC624; whereas the report was not submitted to CCL until 09/34/25. Interviews revealed that four (4) out of seven (7) staff were not accurate of the requirements to report incidents to Community Care Licensing (CCL) division following an injury. Furthermore, S1 confirmed that the facility has not reported this incident to CCL in a timely manner. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

One deficiency has been cited during today's visit.

An exit interview was held with staff one, Paul Gozon - Executive Director (S1) and a copy of this report, citation(s) cited and facilities' appeal rights have been provided to S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20251014124606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish...as the Department may require, including, but not limited to, the following: (1) A written report...for the resident within seven days any..specified in (A) through (D) below.
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LPA and S1 have confirmed that the facility will conduct an in-staff training for all supervisors and med-tech staff who reside at this facility. S1 will forward this documentation to LPA, by email, at MARIO.LEON@DSS.CA.GOV on or prior to POC due date, 10/29/25.
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This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This has not been met as evidenced by a delay in reporting which indicates the licensee has failed to follow
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5