198603118-4-8-2022-11-AS-JHAD-CDXQYZ-20220429123556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 04/08/2022
Date Signed: 04/08/2022 05:15:09 PM

Unsubstantiated

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
04/08/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220408104436

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	JILL TUCKER		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 95	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Camile Bughaw, Director of Memory Care Unit		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility is not maintained at a comfortable temperature.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Camile Bughaw, the Director of Memory Care Unit for the facility.

The investigation consisted of following: Interviews, Toured assisted living and Memory care, and Record reviews. LPA Soto interviewed S#1-Director, S#2 - S#5, R#1 - R#7. Toured assisted living: dining area, lobby, lounge, private dining area, activity room, hallways 1 & 2nd floor, Rooms# 112, 206,207, 209, 212, 216, 218, & 224. Toured Memory Care side: Lobby, Dining room, Lounge, 1st floor hallway, Rooms# 101A, 101B, 102. LPA Soto received the following documents on 04/08/22: Resident Roster, Staff roster, & Repair invoice for A/C Unit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 5

Control Number 11-AS-20220408104436

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: 04/08/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following:

For Allegation #1 – Facility is not maintained at a comfortable temperature. LPA interviewed Director & S#1- S#5, they agreed that the A/C is not working but only is certain areas of the Assisted Living facility. The A/C does work in all the 1st Floor common areas such as:hallways, kitchen, lounge area, activities area, and dining room. 2nd floor common area such as: hallway and lounge. LPA observed the thermostats for the common areas, they were set at 72 degrees Fahrenheit and also LPA felt the facility was at a comfortable temperature. The Staff members, stated that they were working under comfortable temperature conditions. R#4- R#7, liked the temperature at 72 degrees Fahrenheit and above. R#1- R#3, stated they would like the temperature a little cooler. The interviews and record reviews did not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Camile Bughaw, Director of Memory Care Unit and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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
04/08/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220408104436

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	JILL TUCKER		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS:	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Camile Bughaw, Director of Memory Care Unit		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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9

Facility A/C is in disrepair

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20220408104436

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: 04/08/2022

NARRATIVE

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Allegation #2 - Facility A/C is in disrepair. The interviews with Director, S#2 - S#5, agreed that the A/C is not completely operational. The A/C has not worked for more than 2 months. The facility had been trying to repair the A/C unit and provided invoices of the repairs orders for the A/C unit. The A/C unit works for a while and then it shuts down again. The facility has contracted 2 different A/C companies to repair the A/C, One of the companies could not totally fix the A/C, so the facility hired another company. The facility has been actively trying to repair the A/C unit. Currently the facility is waiting on a part that unfortunately is on back order. They are not sure how long more it will be before A/C is completely repaired. The only areas that the A/C is not working in are the residents rooms. Rooms #112, 206, 207, 209, and 224. LPA asked the facility to provide those rooms and any other rooms that might be affected in the future with personal electrical fans. The facility provided the personal fans for the rooms that are being affected at this time. R#1 - R#3 the assisted living side, stated that their rooms were too hot. Staff also stated that they open the windows and doors of the residents rooms to allow for air to circulate into the residents rooms. LPA verified that the A/C was not working in their rooms. The interviews and record reviews did concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Camile Bughaw, Director of Memory Care Unit and a hard copy of report was provided along with the Appeal Rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20220408104436

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2022 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	87303(b) A comfortable temperature for residents shall be maintained at all times. This was not met as evidence by; based on the observations and interviews the facility had A/C cot completely operational. This poses a potential risk for persons in care.	1 2 3 4 5 6 7	Facility to keep providing personal electrical fan to those residents that have no A/C in their rooms. Facility provided personal fans to the residents with no A/C in their rooms. LPA verified the fans in the individuals rooms.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5