198603606-3-19-2024-28-AS-FFIS-D6L2UQ-20240625174242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:48:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/15/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231115094705

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: 89	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Michele Johson- Executive		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent a resident from biting another resident in care.
Staff did not provide adequate supervision to a resident in care.
Staff did not properly conduct a urine test for a resident in care.
Facility illegally evicted a resident in care.
Staff did not ensure that resident was fed.
Staff did not ensure that resident's hygiene needs were being met.

INVESTIGATION FINDINGS:

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**Please note: This report will supersede the report dated 11/30/23 to change information previously noted. However, the findings to all allegations will remain the same: Unsubstantiated.**
Licensing Program Analyst (LPA) V. Maldonado made a subsequent, unannounced, complaint visit to the facility, for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Director, Michele Johnson, and explained the purpose for the visit.
On 11/21/23, LPA Maldonado made an initial complaint visit, to investigate the above-mentioned allegations. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained the following documents for Residents# 1-3 (R1-R3): Facesheet, Physician's Report, Needs and Services Plan, and incicent reports for the months of September-Novemeber 2023. LPA also obtained Medical Records and Shower charts for R1, and Hospital Discharge documents for R2. Interviews were conducted with Staff# 1-3 (S1-S3) and Residents# 3-6 (R3-R6). Telephone interviews were attempted with Staff# 4-6 (S4-S6), however S6 did not answer or call back. Interviews with R1 and R2 were not possible during the visit, due to residents no longer residing at the facility.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 3

Control Number 28-AS-20231115094705

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT GLENDORA	FACILITY NUMBER: 198603606
	VISIT DATE: 03/19/2024

NARRATIVE

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LPA also attempted to conduct a telephone interview with R1's physician, but was unsuccessful.
On 11/30/23, LPA Maldonado conducted a subsequent visit to the facility for the purpose of continuing the investigation. LPA conducted an interview with Staff# 6 (S6).
The investigation revealed the following:
Regarding allegation: Staff did not prevent a resident from biting another resident in care.
It is alleged that on 10/30/23, at about 11:00PM, an incident occurred where R1 wandered into another resident's room and R1 had a bite mark on R1's arm, as R1 was not being monitored properly. Per staff interviews, (5) of (6) staff stated that R3 had pressed R3's pendant for assistance. Upon arrival, staff discovered R3 holding down R1. R1 had bitten R3 and R3 bit R1 back to try to get R1 off from R3. Staff were able to separate the residents and law enforcement was called to file a report. (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was redirected when observed attempting to enter other rooms and staff did not have concerns prior to the incident. Per R1's Physician's Report, dated 9/07/23, it was noted that R1 had a history of aggressive behaviors. Per resident interviews, R3 admitted to biting R1 due to R1 entering R3's room while R3 was sleeping and attempting to pull R3 off R3's bed. R3 stated staff took quick action and were able to remove R1 from R3's bedroom. Per incident report dated 10/30/23, the facility reported the incident of R1 biting R3 and R3 biting R1 in return.
Regarding allegation: Staff did not provide adequate supervision to a resident in care.
It is alleged that facility staff were not aware that R1 was often attempting to enter other resident's rooms and taking their personal possessions, and were not aware of R1's whereabouts. Per staff interviews, (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was easy to redirect when observed attempting to enter other rooms and staff were aware of resident's whereabouts as R1 was always walking the halls, where staff could see R1. (6) of (6) staff stated that no complaints from other residents, or suspicion, that R1 was taking others' personal possessions, was reported. (4) of (6) residents interviewed could not corroborate the allegation.
Regarding allegation: Staff did not properly conduct a urine test for a resident in care.
It is alleged that an LVN at the facility did not properly store or handle a urine sample obtained for R1, as the test results were found to be invalid upon testing, by R1's physician. LPA attempted several times to conduct an interview with R1's physician regarding the allegation, but was unsuccessful. Per staff interviews, (5) of (6) staff could not corroborate the allegation. S1 stated that a urine sample was collected for R1 and results were provided by the lab company. S1 could not recall the exact dates. Per R1's medical records, on 10/03/23, the facility received a physician's order to collect a urine sample. A "Final Report" from the lab company, dated 10/20/23, indicate that a urine sample was collected and received for R1 on 10/18/23 and results regarding the sample were provided to the facility on 10/20/23.
(Report continued on LIC9099-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20231115094705

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT GLENDORA	FACILITY NUMBER: 198603606
	VISIT DATE: 03/19/2024

NARRATIVE

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(4) of (6) residents interviewed could not corroborate the allegation.
Regarding allegation: Facility illegally evicted a resident in care.
It is alleged that on 11/02/23, R1 was informed that R1 needed to leave the facility immediately, without any prior or proper notice. S1 stated that on 11/02/23, R1's responsible party took R1 to the hospital. S1 stated to have contacted R1's responsible party to inquire on R1's return date, which was the following day. S1 was notified shortly after by other facility staff that R1's responsible party had came to pick up R1's furniture and left without notice. Per S6, R1 did not give proper notice prior to moving out. S6 stated that R1's responsible party contacted S6 to inform S6 that R1 was living elsewhere and would not be returning to this facility. S6 denied evicting R1. (6) of (6) staff interviewed stated to not know the reason for R1 moving out of the facility. (4) of (6) residents interviewed could not corroborate the allegation.
Regarding allegation: Staff did not ensure that resident was fed.
It is alleged that staff were not making sure that R1 was eating R1's dinner for the first month that R1 resided at the facility. Per staff interviews, (6) of (6) staff denied the allegation and stated that they would report any issues/concerns of residents refusing meals or not eating. Per R1's Needs and Services Plan, R1 required notice of mealtimes. (6) of (6) staff stated that upon admission to the facility, it was noted that R1 was active and could not sit for a proper meal. However, staff ensured R1 was eating meals by providing more finger foods due to R1 always "on-the-move". Per S1, R1's physician was notified of this. Per R1's medical records, the facility received a physician's order dated 9/29/23, indicating "ok to do finger food". (4) of (6) residents could not corroborate the allegation.
Regarding allegation: Staff did not ensure that resident's hygiene needs were being met.
It is alleged that R1 was combative and facility staff were unable to bathe the resident for three weeks. Per Skin Integrity Monitoring forms, it was discovered that on 9/16/23, it was documented that R1 refused a skin integrity check, and on 10/10/23, it was documented that R1 refused a shower. Per R1's Physician's Report, it was noted that R1 required assistance with baths. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that R1 was combative, however they made all attempts to bathe resident as needed and ensured hygiene needs were met. (4) of (6) residents interviewed could not corroborate the allegation.

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.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Executive Director, Michele Johnson, and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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