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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603606
Report Date: 01/29/2026
Date Signed: 01/29/2026 04:19:56 PM

Document Has Been Signed on 01/29/2026 04:19 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CLEARWATER AT GLENDORAFACILITY NUMBER:
198603606
ADMINISTRATOR/
DIRECTOR:		SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:333 W. DAWSON AVENUETELEPHONE:
(626) 885-0140
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 148CENSUS: 126DATE:
01/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director Michele JohnsonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose of the visit was explained. Executive Director Michele Johnson and Maintenance Director Rene Sandoval assisted with the tour.

The facility is licensed to serve age range 60 and over, 148 non-ambulatory of which six (6) may be bedridden. Bedridden is approved for all first and second floors. The facility has a hospice waiver for 10. Approved for delayed egress. The facility is a two-story building located in a residential area of Glendora operating as an RCFE with a Memory Support unit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Operational Requirements: Facility is operating within the limitations of their license. They have 10 residents under hospice and 1 bedridden resident. LPA observed current liability insurance.

Physical Plant/Environmental Safety: During facility's tour, LPA observed all common areas in good repair. Carbon monoxide and smoke detectors are located in every resident room. A total of 8 residents' rooms for assisted living, and memory support were selected at random for inspection. Each room contained the required furnishing, with sufficient lighting, and bedding supplies. Linens were observed to be clean and in good repair.

continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLEARWATER AT GLENDORA
FACILITY NUMBER: 198603606
VISIT DATE: 01/29/2026
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Water temperature was tested in each resident bathroom and measured between 113°F - 122 ° F, which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and non-slip mats or flooring. Disinfectants, cleaning solutions, and sharps are locked and not left unattended. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded less than 4 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed throughout the facility. Delay egress exit doors were tested and in working condition. Elevators were observed working. There are no pools or large bodies of water.

Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, and personal rights posters were posted in the hallway.

Food Services: LPA toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed.

Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPA reviewed medication for 5 residents. Facility uses EMAR and medications are dispensed as prescribed.

Resident Records/Incident Reports: LPA reviewed 8 residents files. Files were available electronically and each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal.

Disaster Preparedness: LPA obtained a copy of and reviewed emergency disaster plan LIC 610E. Evacuation chairs were observed in staircase. Emergency drills are conducted quarterly; last emergency drill was conducted on 01/22/2026.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLEARWATER AT GLENDORA
FACILITY NUMBER: 198603606
VISIT DATE: 01/29/2026
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Staffing: Administrator certificate was reviewed for Michele Johnson. Documents were submitted in 2023 to licensing for change of Administrator. During today's visit, LPA received documents to review for the change of Administrator. CPR/First aid training was observed for staff.

Personnel Records/Staff Training: LPA reviewed 8 staff files. Files included; TB clearance, health screening, background clearance, personnel record, and training.

Planned Activities: Facility has an Lifestyle Director to coordinate activities provided at the facility. LPAs observed various rooms throughout the facility with puzzles, reading areas, music, crafts, activities and movies.

Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Memory Support unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the Memory Support unit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit.

Exit interview was conducted with Michele Johnson and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
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