198603118-2-12-2026-11-AS-EMAZ-DSRQXA-20260402123314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 02/12/2026
Date Signed: 02/12/2026 05:10:50 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
12/17/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20251217104629

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: 103	DATE:	02/12/2026
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Paul Gozon		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensee did not abide by the admission agreement

INVESTIGATION FINDINGS:

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On 02/12/2026, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Complaint Visit to the facility listed above. LPA met with Apolinario ‘Paul’ Gozon, 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 interviewed Staff S4 and S5, interviewed Residents R1-R12 and received and reviewed Resident R1 and R2’s Physician Report, and email communictaions.
During the initial visit conducted on 12/23/2025, LPA inspected the facility, interviewed Staff S1-S3, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Resident Roster, Residence and Care Agreement Admission Agreement, billing Statement for December 1, 2025, Move-In Prorate Worksheet dated 09/30/2025, Community Fee Receipt dated 09/30/2025, and emails and texts regarding billing concerns.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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-20251217104629

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: 02/12/2026

NARRATIVE

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Allegation: Licensee did not abide by the admission agreement
The allegation alleges that the licensee did not abide by the admission agreement by not disclosing all fees and charges.

During record review, LPA received and reviewed residents R1 and R2’s Residence and Care Agreement, signed and dated 10/01/2025 by R1, that states “This Agreement shall be effective as of 09/30/2025.” Additionally, LPA received and reviewed the Move-In Prorate Worksheet -AL/MS signed and dated on 09/30/2025 by R1, that indicates R1 and R2 were prorated for September 2025 and was charged for one (1) day.

During interviews with Staff S1-S5, they were asked if the move-in incentive and billing is explained to potential or new residents, five (5) out of five (5) stated it is explained and broken down based on the selected apartment, services they sign up for, and level of assistance required. Additionally, Staff S1-S5 were asked if fees and conditions are listed on the Admission Agreements, five (5) out of five (5) stated yes, fees and conditions are listed in the Residence and Care Agreement.
During interviews with Residents R1-R12, they were asked if they were offered an incentive when they moved in and if the incentive was honored, five (5) out of twelve (12) stated yes, they were offered an incentive to move in, and it was honored. Three (3) out of twelve (12) indicated no they were not offered an incentive, or they were not sure. Four (4) out of twelve (12) declined to be interviewed. Resident R1-R12 were additionally asked if the pricing for lodging, assistance, and services were explained to them and listed in the Residence and Care Agreement, eight (8) out of twelve (12) stated yes it was explained to them, and it is listed. Four (4) out of twelve (12) declined to be interviewed. Additionally, during interviews with Residents R1-R12, they were asked if they have been charged a fee or service charge for a service they did not receive, eight (8) out of twelve (12) stated they have not been over charged. Four (4) out of twelve (12) declined to be interviewed

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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(s) is/are unsubstantiated.

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

An exit interview was conducted with Apolinario ‘Paul’ Gozon, Executive Director, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC9099 (FAS) - (06/04)

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