198603606-2-4-2025-28-AS-DSIS-DF7RNZ-20250328131110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:19:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250131095225

FACILITY NAME:	CLEARWATER AT GLENDORA		FACILITY NUMBER:	198603606
ADMINISTRATOR:	SAMPEDRO, TAMMIE		FACILITY TYPE:	740
ADDRESS:	333 W. DAWSON AVENUE		TELEPHONE:	(626) 885-0140
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	148	CENSUS: 115	DATE:	02/04/2025
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Claudia Bauer - Business Office Director Andrea Barraza - Memory Support Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent residents from sustaining multiple falls.
Staff did not prevent residents from sustaining injuries while in care.
Staff left residents in soiled depends for a long period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Claudia Bauer, Business Office Director and Andrea Barraza, Memory Support Director and explained the purpose of the visit.

The investigation consisted of: LPA toured the facility (Assisted Living and Memory Care Unit) and obtained the following documents: Staff and Resident rosters, Memory care staff schedule list, Fall reduction program/policy, Staff In-service training log (dementia care, fall risk, documentation, status checks and changing schedule) and Resident #1 (R1) - Resident #3 (R3)'s file such as: Identification and Emergency Information, Admission Agreement, Physician's Report, Resident Appraisal, Appraisal /Needs and Services Plan, Medication Record/list, Medication Administration Records (Dec. 2024-Jan. 2025), Incident reports (Oct. 2024-Jan. 2025), Daily care/progress notes (Nov. 2024-Jan. 2025), Incontinence change schedule (Nov. 2024-Jan. 2025) and Body check (post falls) documentation (Nov. 2024-Jan. 2025). LPA interviewed Staff #1 (S1) - Staff #4 (S4), Resident #4 (R4) - Resident #12 (R12) and telephonically interviewed Staff #5 (S5). LPA attempted to interview Resident #1 (R1) - Resident #3 (R3) but unsuccessful due to their cognitive abilities.*****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion: 90

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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 28-AS-20250131095225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT GLENDORA	FACILITY NUMBER: 198603606
	VISIT DATE: 02/04/2025

NARRATIVE

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In regards to the allegation: "Staff left residents in soiled depends for a long period of time." It is alleged that staff observed multiple residents left in their feces and urine for a few hours last week. (4) out of (5) staff interviewed denied the allegation and stated that they have adequate staffing at this time. S1 stated that they do staffing based on acuity and there are 4-5 staff assigned per shift. Staff stated that they conduct rounds every 2 hours per shift or as needed, not only to change undergarments for incontinent residents, but to check if residents are doing well or need other assistance. Interviewed residents denied the allegation. (5) incontinent residents who were interviewed stated that staff assist them all the time in toileting, changing and never left them in soiled undergarments. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of residents' files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

Exit interview conducted and a copy of this report was provided to Andrea Barraza, Memory Support Director.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250131095225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT GLENDORA	FACILITY NUMBER: 198603606
	VISIT DATE: 02/04/2025

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: "Staff did not prevent residents from sustaining multiple falls." It is alleged that most of the residents are falling out of their beds and staff are not doing anything to prevent the falls. And recently, a resident who is a fall risk, fell when getting out of bed. 4 out of 5 staff interviewed denied the allegation and stated they have adequate staffing. Staff interviewed stated that they have completed training regarding fall risk, dementia care and documentation. S1 stated that majority of the residents do not have one-on-one care. S1 stated that the facility has a fall reduction program and staff are aware of the protocol to prevent residents from falling. Interviewed staff indicated that they use different intervention techniques to prevent them from falling like providing fall mats, bed rails for hospice residents, do strength and balance exercises to improve their balance, encouraging residents to stay in the common areas, and/or attend activities for extra supervision. Interviews with residents stated that staff do all the best they can to prevent the residents from falling. Some interviewed residents who experienced a fall stated that the staff conducted body checks, assessed and provided first aid on them. Interviewed residents stated that staff are supportive and conduct routine checks daily. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation:"Staff did not prevent residents from sustaining injuries while in care." It is alleged that there have been multiple falls at the facility and residents have sustained black eyes and “busted faces” due to these falls. Additionally, a resident fell and hit her face on the night stand, resulting in a cut on her face close to her eyebrow. Interviewed staff denied the allegation. S1 stated that she was aware that R2 who is receiving hospice care experienced an unwitnessed fall and when it occurred, R2 was promptly attended to, evaluated and underwent a body check by the staff. S1 stated that R2 did not have a one-on-one care and that R2 had a minor cut above her eyebrow, but there was no apparent trauma. Nonetheless, 911 was called to assess R2 and the paramedics suggested transporting R2 to the hospital. R2 was not hospitalized and did not sustain major injury. Interviewed staff indicated that they use different intervention techniques to prevent residents from falling and sustaining injuries like providing fall mats, bed rails for hospice residents and encouraging residents to stay in the common areas, and/or attend activities for extra set of eyes. Interviews with residents stated that staff do all the best they can to prevent residents from sustaining injuries. Interviewed residents stated that staff assist them with their needs and monitors them regularly. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC9099 (FAS) - (06/04)

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