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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:00:50 PM


Document Has Been Signed on 02/28/2022 04:00 PM - It Cannot Be Edited

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
MONTERY PARK, CA 91754



FACILITY NAME:CLEARWATER AT SOUTH BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:JILL TUCKERFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 95DATE:
02/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Jill TuckerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced Case Management visit to Clearwater at South Bay. LPA met with Administrator Jill Tucker and explained the purpose of today’s visit is to serve an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY for Staff #1.

An investigation conducted by the California Department of Social Services determined that Staff #1 violated California Code of Regulations Title 22 for the client’s personal rights. Health and Safety Code 1569.58 was also issued, informing the administrator that an excluded person may petition for reinstatement to the Department one year after the effective date of the exclusion order.

LPA Montoya gave a copy of the Immediate Exclusion letter for Clearwater at South Bay to Administrator Jill Tucker.

LPA Montoya served the ORDER TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM FACILITY to Staff #1.



Administrator Jill Tucker stated she understood the Immediate Exclusion order and that she understands the mentioned staff is not allowed to be physically present in the facility.

LPA Montoya conducted a health and safety inspection, reviewing the physical plant and the facility’s food supply.

An exit interview conducted, and a copy of this report was given to Administrator Jill Tucker.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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