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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603606
Report Date: 02/28/2025
Date Signed: 03/12/2025 01:09:59 PM

Document Has Been Signed on 03/12/2025 01:09 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: 111DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administartor Michele JohnsonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Executive Director Michele Johnson at approximately 8:00 AM and explained reason for visit.

The facility is a two-story building with a memory care unit, operating as a Residential Care Facility for the Elderly. It is licensed to serve (148) older adults, ages 60 and over. There is a fire clearance approved for (148) non-ambulatory residents, of which (6) may be bedridden, and includes bedridden rooms approved on both first and second floors and delayed egress. There are currently (10) residents receiving hospice care. It has an approved Dementia Care Plan and a Hospice Waiver approved for (10) residents.

LPA observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility has a commercial kitchen. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The call system was tested in resident bedrooms and were operational. The facility is equipped with surveillance cameras in common areas. One water fountain was observed in the center of the assisted living side, courtyard; however, it contained a small amount water. There is a shaded seating area for the residents located. Passageways and exits are free of obstruction.

SEE LIC 809c

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 01:09 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 02/28/2025 at 02:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out of three (3) residents medications were missing a medication JANUMET 50-500 MG given in evening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2025
Plan of Correction
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Health Services Director Jonna Mendoza ordered medication at time of visit. Administrator will send picture by email once medication is delivered.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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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: 02/28/2025
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Seven (7) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Ten (10) residents files were reviewed and included physicians report, TB clearance, and appraisal needs and service plan. Last fire/earthquake drill was conducted in February of 2025. Infectious control plan was reviewed. Three (3) staff and six (6) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked MAR log is used. LPA observed R11 medication missing Deficiency cited.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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