198603118-8-18-2026-11-AS-EMAZ-DXARY5-20260825132546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 08/18/2026
Date Signed: 08/18/2026 04:05:03 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
06/18/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260618083343

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: 105	DATE:	08/18/2026
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Diane ‘Dee’ Navarro		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not ensure resident's hygiene needs were met
Staff locked resident out of bedroom
Staff left resident on the floor for an extended period of time
Staff did not allow resident to have a visitor
Staff confined resident to bedroom
Staff do not treat residents with dignity and respect.

INVESTIGATION FINDINGS:

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On 08/18/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Diane ‘Dee’ Navarro, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation revealed the following:
During the initial visit conducted on 06/25/2026, LPA inspected the facility, interviewed Staff S1-S7, interviewed Residents R1-R12, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Admission Agreement (dated 02/11/2026), Needs and Service Plan, Power of Attorney documents, Health Information Release Authorization (dated 08/11/2025), Request to Restrict Use or Disclosure of Health Information (dated 08/11/2025), SafelyYou Program Resident Consent (dated 02/05/2025), Torrance Police Department incident card from 06/12/2026, Preplacement Appraisal Information (dated 08/11/2025), Notes & Incidents from 02/022026 through 06/20/2026, Emails between the facility and the Power of Attorney (POA), and business card for R1’s Court Appointed Attorney of Law.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

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-20260618083343

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: 08/18/2026

NARRATIVE

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Allegation: Staff did not ensure resident’s hygiene needs were met
The allegation alleges a resident’s hygiene has become poor due to staff not allowing a resident to wash their face or brush their teeth.

During the facility inspection, LPA observed Staff assisting Residents with activities of daily living, including ambulating, toileting and incontinent care, dressing and changing, grooming, and bathing.

During record review, LPA received and reviewed the Residence and Care Agreement, signed and dated 01/13/2026, and observed on page 5 under, II. Personal Assistance and Care states “In accordance with your plan of care and applicable California law, we will provide you assistance, as needed, with activities of daily living, such as bathing, dressing, ambulating, and assistance with medications.” LPA received and reviewed the Service Plan, dated 02/06/2026, for Resident R1 that indicates R1 requires full assistance with bathing, dressing, grooming, medications, and ambulating. LPA observed R1 requires standby assistance with oral care, toileting, and transfers.
During interviews with Staff S1-S7, were asked how much time they allow to assist a resident with hygiene needs, seven (7) out of seven (7) stated the residents takes as long as they need.
During interviews with Residents R1-R12, were asked if staff allow them time to perform hygiene tasks, twelve (12) out of twelve (12) stated they take as long as they need.

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.

Allegation: Staff locked resident out of bedroom

The allegation alleges that when a resident leaves their room in the morning, staff lock their door for hours.

During the facility inspection, LPA observed some doors were locked and closed and others were unlocked and/or open. LPA observed residents being escorted by staff to and from their rooms. During interviews with residents, LPA observed residents have their own room key on a band around their wrist or on a string around their necks.

During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement Appendix A-Schedule of Fees for Additional Item and Services, signed and dated 01/13/2026, that indicates a fee will be charged for any lost room keys and fee will be charged for re-keying of apartment due to lost keys. Additionally, in the Resident Handbook signed and dated 01/13/2026, on page 15, under Security, states “Keep you door locked when away from home.”

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20260618083343

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: 08/18/2026

NARRATIVE

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During interviews with Staff S1-S7, were asked if they lock residents out of their room during the day, seven (7) out of seven (7) stated no, they do not lock resident’s out of their rooms.
During interviews with Residents R1-R12, were asked if there was a time staff locked them out of their room, twelve (12) out of twelve (12) stated no, staff have not locked them out of their room. Additionally, twelve (12) out of twelve (12) residents showed they have a key to their rooms.

Allegation: Staff left resident on the floor for an extended period of time

The allegation alleges that a resident experienced a fall, and staff did not find them for an extended period of time.

During the facility inspection, LPA observed caregivers going to resident’s rooms, knocking, asking if they can come in, and once in they asked the resident if they require or need anything.

During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated on 01/13/2026, that states on page 2 “We encourage our residents to participate in physical activities to the extent of their capabilities. Thus, falls and other personal injuries may occur from time to time.” LPA received and reviewed SafelyYou Program Resident Consent, signed and dated 02/05/2025, that states on page 1, “SafelyYou utilizes artificial intelligence (AI) software and electronic monitoring hardware to detect falls, identify health and safety risks, and detect care delivery pattern.” Additionally, it states “ The SafelyYou system does not have perfect accuracy and may experience periods of downtime or system interruptions.” LPA received and reviewed Resident R1’s Service Plan, signed and dated 02/06/2026, and observed R1 receives full assistance with transfers and mobility as fall precautions. LPA received and reviewed Resident R1’s Notes and Incidents-Resident Summary LPA observed on 02/15/2026, Resident R1 experienced two (2) falls. On 02/15/2026 at 12:29am, staff received a notification from SafelyYou indicating R1 experienced a fall. Upon review of the footage, R1 tried to get up out of bed and lost their balance, and fell after refusing incontinent assistance from staff. The second incident occurred on 02/15/2026 at 3:22am, staff received notification from SafelyYou indicated R1 experienced a fall. Upon review of the footage, R1 stood up getting out of bed, began walking towards walker and lost their balance. LPA observed R1 experienced an additional fall on 04/14/2026 at 8:39am. R1 was found on the floor next to their bed by caregiver. Resident R1 did not complain of any pain or discomfort and no visible injuries. R1 was agitated that they were on the

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20260618083343

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: 08/18/2026

NARRATIVE

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floor.
During interviews with Staff S1-S7, were asked if there was a time a resident was found on the ground for an extended period of time, seven (7) out of seven (7) stated no, a resident has not been left on the ground for an extended period of time.
During interviews with Residents R1-R12, were asked if they experienced an emergency and did not receive assistance for an extended period of time, twelve (12) out of twelve (12) stated no, they have not been left on the floor for an extended period of time.

Allegation: Staff did not allow resident to have a visitor

The allegation alleges staff are not allowing a resident to have specific visitors per the power of attorney’s request.

During the facility inspection, LPA observed resident visitors coming into the facility, checking in at the front desk, and going to the area of the facility their family was in.

During record review, LPA received and reviewed Resident R1’s Notes and Incidents-Resident Summary that states on 06/17/2026, R1’s POA met with S1 and Memory Support Director, to discuss the incident that occurred on 06/12/2026 with a family member. R1’s POA was made aware the community placed a no trespass notice for the family member after the disruption and screaming and yelling in front of other residents resulting in staff having to call 911. LPA received the Torrance Police Department incident card, 260022933, for their call out on 06/12/2026 when they were called to assist with having a visitor for Resident R1 removed from the facility due to disruptive behavior. LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated 01/13/2026, and observed on page 20, under F. Guests Visits and Communications that states “Your guests are welcome to visit…provided they respect the rights of other residents and staff and abide by our visitor and guest policies…” Additionally on page 21 it states, “You will be responsible for assuring that your guests abide by these rules and are not disruptive.” Additionally, LPA observed on page 21 it states, “We reserve the right to remove or deny entry to Clearwater at South Bay to any visitor whom we determine disruptive or dangerous.” LPA received and reviewed Resident R1’s Admission Agreement Appendix G-Statement of Resident’s Personal Rights, signed and dated 01/13/2026, that states on page 2 residents have the right “to consent

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20260618083343

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: 08/18/2026

NARRATIVE

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to have their relative and other individuasl of their choosing visit during reasonable hours, privately, and without prior notice.”
During interviews with Staff S1-S7, were asked if they have denied a resident’s visitor, seven (7) out of seven (7) stated no, they have not denied a resident’s visitor unless there is a court order, no trespass order, or the conservator has the authority to make that decision.
During interviews with Residents R1-R12, were asked if staff have denied a visitor, eleven (11) out of twelve (12) stated no, staff have not denied their visitors. One (1) out of twelve (12) stated yes, staff have denied a visitor due to their visitor’s actions at the facility.

Allegation: Staff confined resident to bedroom

The allegation alleges staff locked a resident in their room.

During the facility inspection, LPA observed residents in common areas watching television, talking with other residents or staff, and participating in activities and exercise. LPA tested resident rooms, by having staff lock the door from the outside, and the LPA was able to easily exit by pushing down on the door handle.

During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated 01/13/2026, that states on page 1, “Clearwater at South Bay is not permitted to use restraints on its residents, and the use of restraints is also inconsistent with our philosophy.” LPA received and reviewed Admission Agreement Appendix G-Statement of Resident’s Personal Right, that states resident have the right “to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night." LPA received and reviewed Resident R1’ Service Plan, dated and signed 02/06/2026, that indicates in the Psycho-Social Engagement, R1 is “actively involved in community life.”
During interviews with Staff S1-S7, were asked if they have confined a resident to their room, seven (7) out of seven (7) stated no, they have not confined a resident to their room.
During interviews with Residents R1-R12, were asked if there was a time they were confined to their room, twelve (12) out of twelve (12) state no, they have not been confined to their room.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20260618083343

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: 08/18/2026

NARRATIVE

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Allegation: Staff do not treat residents with dignity and respect
The allegation alleges staff are instructed to follow a resident while in the facility causing the resident to feel uncomfortable.

During the facility inspection, LPA observed staff escorting residents to their rooms, activities, and meals.

During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement Appendix G-Statement of Residents’ Personal Rights, that states “Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff, residents, and other persons. LPA received and reviewed Resident R1’s Service Plan, which indicates under Mobility, R1 needs full assistance that includes escorting to meals and activities to ensure overall wellbeing.
During interviews with Staff S1-S7, were asked how they treat residents with respect and dignity, seven (7) out of seven (7) stated they listen to their wants and need and respect their privacy.
During interviews with Residents R1-R12, were asked if staff treat them with respect and dignity, twelve (12) out of twelve (12) stated yes, staff treat them with respect and dignity.

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

An exit interview was conducted with Diane ‘Dee' Navarro, Memory Support Lifestyle Director, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

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