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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 05/05/2021
Date Signed: 05/19/2021 03:21:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CLEARWATER AT SOUTH BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:MICHAEL KRIEGERFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 77DATE:
05/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Michael KriegerTIME COMPLETED:
11:49 AM
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On 05/05/2021 Licensing Program Analyst (LPA) Don Senaha conducted a Case Management visit at Clearwater At South Bay. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually via facetime with Michael Krieger/Administrator and Jamie Pyles/Health Services Director. LPA explained the purpose of the visit was to gather information.

LPA Senaha received incident reports (LIC 624) via fax on 05/03/2021 from Jamie Pyles/Health Services Director (HSD) regarding unwitnessed falls of a resident (R1) on 04/24/2021 and a second fall on 04/29/2021.

During today’s visit LPA interviewed Health Service Director and conducted an inspection of the resident’s (R1) room. Resident (R1) was not able to interview at the time of the visit.

No deficiencies were found. LPA requested additional information to include a copy of resident’s (R1) physicians report, needs and service plan, progress notes, prescription order chart, current medications/treatments and fall risk plan.

A telephonic exit interview via facetime was conducted with Michael Krieger and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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