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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 07/06/2026
Date Signed: 07/06/2026 04:39:02 PM

Substantiated


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
06/29/2026 and conducted by Evaluator Gabriela Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260629103741
FACILITY NAME:CLEARWATER AT GLENDORAFACILITY NUMBER:
198603606
ADMINISTRATOR:MICHELE JOHNSONFACILITY TYPE:
740
ADDRESS:333 W. DAWSON AVENUETELEPHONE:
(626) 885-0140
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:148CENSUS: 111DATE:
07/06/2026
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:William Bill Boles, Executive Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not providing adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 07/06/2026 to deliver findings regarding the above allegation. LPA was greeted by Executive Director William Boles and facility staff. LPA explained the purpose of the visit.

During the investigation, LPA reviewed and obtained copies of the Resident Roster, Staff Roster, R1's Face Sheet, R1's Admission Agreement, R1's Care Plan, R1's individualized food menu, food service delivery logs, Resident Meal Documentation Forms, concierge email communications, and the employee Performance Counseling Memo related to the incident. LPA also conducted a tour of the facility and interviewed five (5) staff members (S1–S5) and four (4) residents (R1–R4). The investigation further included a review of the facility's meal delivery documentation and records pertaining to the allegation.

(continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
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 3
Control Number 28-AS-20260629103741
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/24/2026
Section Cited
CCR
87555(b)(1)
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(b) The following food service requirements shall apply:
(1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement was not met as evidenced by:

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The licensee shall submit a written plan describing how the facility will ensure residents receiving in-room meal service receive all scheduled meals. The licensee shall provide proof that staff have been trained on the meal delivery procedures and how missed meals will be documented and prevented.
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Based on interviews and records reviewed, it was determined that the facility failed to provide R1 with theor scheduled lunch meal on 06/26/2026, as required. The facility's failure to ensure R1 received her scheduled meal poses/posed an immediate risk to the resident's health, safety, and personal rights.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20260629103741
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: 07/06/2026
NARRATIVE
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Allegation: Staff are not providing adequate food service

It is alleged that facility staff failed to provide adequate food service by not delivering a scheduled meal to a resident receiving in-room meal delivery services. Specifically, it is alleged that R1 did not receive her lunch on June 26, 2026, despite being enrolled in the facility's meal delivery program, and that similar incidents have occurred on prior occasions. During staff interviews, staff explained that R1 receives her meals in her room and that the culinary staff are responsible for preparing and delivering meals to residents receiving in-room meal service. Staff reported that the facility utilizes meal tracking tools, Resident Missed Meal Documentation Forms, and concierge communication to monitor meal deliveries and identify missed meals. Staff also stated that residents' families may occasionally arrange outside food deliveries or take residents into the community for meals and notify the concierge when a facility meal is not needed. Initially, staff were unaware of any missed meal involving R1 on 06/26/2026. However, after reviewing concierge email communications and additional documentation, staff confirmed that R1 did not receive her scheduled lunch on 06/26/2026 because a staff member failed to deliver the meal. Staff further confirmed that the employee received disciplinary action for failing to follow the facility's meal delivery procedures. R1 stated that her meals are routinely delivered to their room and recalled missing a meal. R1 reported that when they do not receive a meal, they contact their daughter rather than notifying facility staff. Interviews with R2 through R4 revealed no concerns regarding the facility's meal service or food delivery, and the residents reported they consistently received their meals as scheduled. Documentation reviewed, including concierge email communications, meal delivery records, and the employee Performance Counseling Memo, corroborated that R1 did not receive her scheduled lunch on 06/26/2026 and that the facility addressed the incident through employee disciplinary action.


Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3