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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 04/23/2024
Date Signed: 04/23/2024 11:52:48 AM

Substantiated


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
10/31/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231031163231
FACILITY NAME:CLEARWATER AT GLENDORAFACILITY NUMBER:
198603606
ADMINISTRATOR:SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:333 W. DAWSON AVENUETELEPHONE:
(626) 885-0140
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:148CENSUS: 96DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Michele Johnson - Executive Director TIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff did not prevent the resident from attacking another resident resulting in injuries.
Staff did not prevent residents from disturbing other residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit regarding the above allegations. LPA met with Michele Johnson and explained the reason for the visit.

The investigation consisted of the following: On 11/7/23 LPA Galarza conducted an unannounced health and safety visit at the facility no deficiencies were noted during that visit. Documents were collected: resident #1-#3 (R1 - R3) file documents, incident reports, maintenance work orders, cycle meal menus from July to October 2023, special diet list, food handling certificates, kitchen server "to do list", dietician services agreement, resident roster, and LIC 500 Personnel Report.On 11/7/23 Investigation Bureau of the Department(IB), Investigator Laura Garcia was assigned to conducted interviews with staff, family members, and obtained medical records for R1 and R2. On 3/25/24 LPA Flores interviewed 3 staff over the phone. On 4/23/24 LPA Flores interviewed 3 additional staff and 7 residents, toured the memory care unit observed 7 random rooms and delivered findings.

(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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 5
Control Number 28-AS-20231031163231
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: 04/23/2024
NARRATIVE
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The investigation revealed the following: regarding allegations: Staff did not prevent the resident from attacking another resident resulting in injuries and Staff did not prevent residents from disturbing other residents. It is alleged R2 is wandering and randomly going into residents’ rooms and on 10/30/23 R2 went into R1’s room, punched R1 in the face, stomach, leg and pulled R1 off the bed, and R1’s roommate was attacked as well. On 10/30/23 facility staff called 911 and requested services due to an assault at the facility. Upon arrival of police officer and paramedics. Police officer observed R1 was being treated by fire department paramedics with blood dripping from the left side of the head. R1 stated at that time to have been pulled of the bed and pushed by a resident causing R1 to fall and getting hurt. Staff assisting R1 stated that R2 had also attacked Resident #4(R4), R1’s roommate. R1 was taken to the hospital and was treated for a head contusion and laceration on the left side of the head. Interviews conducted revealed that 5 out of 5 staff interviewed by IB investigator stated to be aware of R2’s aggressive and wandering behaviors. A staff stated R2 had shown aggressive behavior towards two staff providing care, one of those two staff was injured. Staff also stated that R2 had punched R3 in the past. However, no changes to R2’s care were provided. R2’s nurse practitioner stated also to be aware of the incidents and R2’s behavior. Document review revealed, on 10/27/23, R2’s needs and service plan was updated noting R2 needs 2-3 caregivers to assist with R2’s care and nurse practitioner noted an adjustment for medication due to behaviors. Based on investigation conducted R1 was seriously injured at the facility by R2. The facility was aware of R2’s behaviors and no additional supervision was provided during shifts or shift changes to prevent R2 from entering other resident’s rooms and/or prevent aggressive behavior towards other residents.
Based on interviews and review of documentation regarding the allegation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 sustaining a laceration to the head due to lack of supervision of Resident #2 while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.

Exit interview was conducted with Michele Johnson and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20231031163231
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents...: (a)... shall...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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 Administrator will certify in writing and create a plan which will address the steps to take when a circustance of wandering and aggressive behaviors are observed in a resident to the department by POC due date 4/24/24.
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Based on document review and interviews licensee did not ensure R2 was provided with supervision due to aggressive behaviors to prevent R1 obtaining laceration to the head which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #2 sustaining a laceration to the head due to lack of supervision of Resident #1 while in care. Refer to LIC 421IM***
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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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/31/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20231031163231

FACILITY NAME:CLEARWATER AT GLENDORAFACILITY NUMBER:
198603606
ADMINISTRATOR:SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:333 W. DAWSON AVENUETELEPHONE:
(626) 885-0140
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:148CENSUS: DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Michele Johnson - Executive Director TIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff not providing resident with meal(s).
Resident’s toilet is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit regarding the above allegations. LPA met with Michelle Johnson and explained the reason for the visit.

The investigation consisted of the following: On 11/7/23 LPA Galarza conducted an unannounced health and safety visit at the facility no deficiencies were noted during that visit. Documents were collected: resident #1-#3 (R1 - R3) file documents, incident reports, maintenance work orders, cycle meal menus from July to October 2023, special diet list, food handling certificates, kitchen server "to do list", dietician services agreement, resident roster, and LIC 500 Personnel Report.On 11/7/23 Investigation Bureau of the Department(IB), Investigator Laura Garcia was assigned to conducted interviews with staff, family members, and obtained medical records for R1 and R2. On 3/25/24 LPA Flores interviewed 3 staff over the phone. On 4/23/24 LPA Flores interviewed 3 additional staff and 7 residents, toured the memory care unit observed 7 random rooms and delivered findings.

(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20231031163231
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: 04/23/2024
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff not providing resident with meal(s).
It is alleged the cooks do not send food over to the memory care side and meals are not being provided to resident during mealtimes. Interviews conducted revealed 6 out of 7 residents interviewed stated to receive 2-3 meals a day, residents have not missed a meal, and meals are timely every day. 1 out of 7 residents interviewed stated the food can be late hours. Interviews with staff revealed food is serve timely, food is provided to memory care unit before it is provided to the assisted living section, and food is brought to the memory care unit by the servers. LPA observed memory care unit’s kitchen which provides an area to maintain meals warm and be able to serve residents in the dining area. Per documents review the facility has a menu designed to accommodate the needs of the residents and the staff are qualified to prepare and provide meals.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Resident’s toilet is in disrepair. It is alleged on multiple occasions toilet in resident’s room has been overfilled to the “brim” with urine and feces. Interviews conducted revealed, 7 out of 7 residents interviewed stated that the toilet is always in working condition. Interviews conducted with staff revealed, facility has a system in which work orders are added for maintenance department to response. Per staff, maintenance department responds right away, even thought they have 36 hours to respond and repair anything in the work order. If a toilet is clogged the maintenance department responds even faster and in addition plungers can be found in the maintenance closets accessible to any staff to assist with unclogging the toilets if needed. LPA Flores observed 7 rooms in the memory care unit and each room had a working toilet at the time of the visit. Documents reviewed revealed three work orders for the following dates: 7/25/23, 8/25/23, and 9/28/23 for clogged/overflowing toilet in room #123 in which one of the reports shows it took 30 minutes to resolve and each was place in the evening after 4:45pm and set as completed by the next day before 11:10am.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Michele Johnson and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5