198603606-1-21-2026-28-AS-LHIS-DQRMFD-20260128083407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 01/21/2026
Date Signed: 01/21/2026 03:30:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
12/18/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251218103514

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: 111	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Michele Johnson - Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee does not ensure an adequate supply of PPE is provided for staff.
Licensee did not ensure infection control measures were properly implemented.
Staff did not maintain documentation of the resident’s medical history and current health status.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Michele Johnson, Executive Director and explained the purpose of the visit.

The investigation consisted of the following: On 12/23/2025, LPA toured the facility, inspected PPE supplies, obtained/reviewed copies of the staff and resident rosters, Invoices for PPE supplies (last 3 months), and Resident #1 (R1) - Resident #3 (R3) files. LPA also interviewed Staff #1 (S1) - Staff #5 (S5). LPA also requested the Executive Director/House Services Director to email additional documents pertinent to the investigation.

During today's visit, LPA obtained resident & staff rosters, additional documents related to the investigation such as Hospice nurse noted and interviewed Witness #1 (W1) and Resident #1 (R1) - Resident #10 (R10) from Memory Care and Assisted Living units. *****CONTINUED ON LIC 9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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-20251218103514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/21/2026

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: "Licensee does not ensure an adequate supply of PPE is provided for staff." It is alleged that facility has inadequate supply of PPE for staff to use while providing care to the resident, and prior to entering the resident rooms and no PPE for staff to use the first 2 days. (5) of (6) staff interviewed stated that PPE supplies are adequate and available for staff to use. Some staff indicated that they conduct weekly audits of their supplies such as gloves, masks, med cups, hand sanitizers and replenish them as needed. S2 stated that their PPE supplies are ordered through Amazon which offers expedited delivery, often with same-day delivery. (1) of (6) staff interviewed stated that although they don't know where to get the PPE supplies, they get it from their supervisor if they ask. (10) of (10) residents interviewed denied the allegation and stated that the facility always have masks or sanitizers available. During the visit on 12/23/2025, LPA observed sufficient stocks of PPE supplies in cabinets in the med room, storage room and in the office of the House Services Director. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: "Licensee did not ensure infection control measures were properly implemented." It is alleged that on 12/16/2025, staff learned that R1-R3 have different kinds of infections and found out of their infections during shift change since the administrator did not inform them of this. Staff interviewed stated that the hospice nurse for R1 visited R1 on 12/15/2025 and ordered a new antibiotic medicine because there was a high probability that R1's illness was contagious. However, some staff stated that they still followed the infection control guidelines, although there was no confirmed diagnosis that R1 has an infectious disease. Some staff stated that they were using gloves and masks when providing care to R1. S6 stated that PPE supplies such as gowns, masks, and gloves were placed outside the residents’ rooms on the same day they learned about the infection. On the evening of 12/16/2025, S6 also stated that they texted the care team with the preventative measures and instructions. Documents reviewed revealed that staff were trained on infection control measures and the facility has implemented guidelines. Therefore, there was insufficient evidence to corroborate with this allegation.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251218103514

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/21/2026

NARRATIVE

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In regards to the allegation: "Staff did not maintain documentation of the resident’s medical history and current health status." It is alleged that on 12/16/2025, R1-R3 have infections but the administrator did not tell any of the direct staff about any of the residents infections. Additionally, when R1 was admitted to the facility, this recurring infection information was never noted in their chart history. Some staff stated that they were not aware of R1's pre existing condition as they were not listed on R1's medical history nor the current physicians report. Some staff interviewed stated that when they notified R1'sfamily about the infection flare up, the family said that they were aware of R1's condition a long time ago, but forgot to mention it to the facility staff when R1 was pre-appraised. (10) out of (10) residents interviewed stated that the staff maintain a record of their medical history as well as their current health status. Based on documentation reviewed by LPA, the staff failed to communicate and flag R1-R3's complex or changing health needs to the care team, however, the facility maintain a timely chart documentation of R1-R3's care plan and medical records. Additionally, facility conducts staff training on documentation. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident 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.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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