198603118-5-17-2021-11-AS-MVAO-C3KPLR-20210601112510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 05/11/2021
Date Signed: 05/17/2021 01:21:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/08/2021 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210208145723

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	MICHAEL KRIEGER		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 75	DATE:	05/11/2021
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Michael Krieger		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff are hitting residents.
Residents sustained injuries while in care.
Facility is not administering medications as prescribed.
Facility is not ensuring residents are getting their meals.

INVESTIGATION FINDINGS:

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On 05/11/2021 Licensing Program Analyst (LPA) Don Senaha and Licensing Program Manager (LPM) Eva Alvarez conducted a subsequent visit to deliver complaint findings. LPA met with Administrator Michael Kreiger and explained the purpose of the visit.

On 2/11/21 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via Microsoft Teams tele-visit with Administrator Michael Krieger.

The investigation consisted of the following: Interviews conducted with Michael Krieger (Administrator), residents (R1-R11), staff (S1-S10) and witness (W1). (R1, R5-R6) declined to be interviewed. LPA obtained and reviewed staff and client roster, menu calendar, medical records and medication administration records regarding the allegations. A plant inspection of the facility was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

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 3

Control Number 11-AS-20210208145723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 05/11/2021

NARRATIVE

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Allegation: Staff are hitting residents
LPA conducted interviews with residents (R2-R4, R7-R8, R10-R11). Residents (R2-R4, R7-R8, R10-R11) stated they have never been struck by a staff member. Residents (R2-R4, R7-R8, R10-R11) stated they have never seen a staff member hit or strike a resident in the facility.

LPA conducted interviews with staff (S1-S10). Staff (S2-S5, S7-S10) stated they have never been physical with a resident. During the interviews, staff (S1, S7) stated the facility has training for all new employees regarding workplace violence. LPA obtained copy of list of training programs for staff on Relias system which included: Reporting Elder and Dependent Adult Abuse in California, Challenging Behaviors in Dementia Care, Communicating with People with Dementia and Workplace Violence.

Based on the interviews conducted, LPA was unable to find evidence to support the allegation.
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Allegation: Residents sustained injuries while in care
LPA conducted interviews with residents (R2-R4, R7-R8, R10-R11). Residents (R4, R7, R10-R11) stated they have not sustained injuries while in care. Residents (R2-R3 and R8) stated they had sustained injuries due to falling and were transported to the hospital for treatment. Residents (R2-R3 and R8) stated staff responded immediately and appropriately and did not express any concerns regarding the response of staff when the injury occurred.

LPA conducted interviews with staff (S1-S10). Staff (S2) stated the residents do fall sometimes and they are sent to the hospital, but staff (S2) could not recall any recent injuries. Staff (S6) stated there have been three residents she can recall as far back as January 2020 that went to the hospital. LPA reviewed incident report (LIC 624) reported for each resident. Staff (S8) stated he recalls one resident transported to the hospital a few weeks ago. LPA reviewed incident report (LIC624) reported for this resident. Staff (S1-S10) stated when residents are injured, they are transported to the hospital.

Based on the interviews conducted, observation and records reviews, LPA was unable to find evidence to support the allegation.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210208145723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 05/11/2021

NARRATIVE

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Allegation: Facility is not administering medications as prescribed
LPA conducted interviews with residents (R2-R4, R7-R8, R10). Residents (R2-R3, R7-R8, R10) stated the staff assists them to take their medications. During interviews with residents (R2-R3, R7-R8, R10), residents did not express any concerns in receiving their medications in a timely manner.

LPA conducted interviews with staff (S2, S3, S6, S10). Staff (S2-S3, S10) stated they are administering medications according to doctors’ orders as prescribed. Staff (S6) stated “the med techs follow the six rights of medication administration”. LPA reviewed the Medication Administration Record (MARs) of residents (R1-R6) for December 2020, January 2021 and February 2021. LPA found the MARs to be complete with no missed dosages.

Based on the interviews conducted and records reviews, LPA found no evidence that the facility is not administering medications as prescribed.

Allegation: Facility is not ensuring residents are getting their meals

LPA conducted interviews with residents (R2-R4, R7-R8, R10-R11). Resident (R2) stated sometimes he chooses to skip dinner if he eats too much breakfast and lunch and can always ask for a snack later if he becomes hungry. Residents (R3-R4, R7-R8, R11) stated they always are served breakfast, lunch and dinner meals.

Staff (S1, S3-S10) stated residents are served breakfast, lunch and dinner every day, plus snacks between meals and/or when requested. LPA obtained a weekly at a glance menu. LPA found no issues with the food service requirements.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Michael Krieger and a hard copy was provided for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

LIC9099 (FAS) - (06/04)

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