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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:44:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CLEARWATER AT NORTH TUSTINFACILITY NUMBER:
306006040
ADMINISTRATOR:SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:11901 NEWPORT AVETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:124CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tammie SampedroTIME COMPLETED:
12:50 PM
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Licensing Program Analysts (LPAs) Jerome Haley and Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. The Agency received the application for Licensure on 7/19/2021. LPAs were greeted and granted entry by facility staff and completed a Covid-19 screening upon entering the facility. President Danielle Morgan and Executive Director Tammie Sampedro led us on a tour of the facility. LPAs observed all staff wearing masks. Facility is to operate an Adult Residential Facility for the Elderly (RCFE) with a capacity of 124 of which 118 can be non-ambulatory, 6 bedridden. LPAs observed the facility has the PUB 475 poster (See Something Say Something) 20 X 26 inches, that will be mounted in the front lobby of the facility. Staff reported the Council on Aging poster (Ombudsman) poster has been ordered and will be mounted in the front lobby area. Structure; Facility is composed of 2 one story buildings, Assisted Living which has 72 resident units and Memory Care which has 28 resident units. LPAs observed no obstacles or hazardous in the facility. There was a variety of different rooms in the assisted living portion of the facility: a game room equipped with a pool table, wellness center for fitness and physical therapy, beauty salon and multipurpose theater room, and a creative arts studio. LPAs observed first aid kits in the employee only cleaning storage closets and the medication room. LPAs observed all fire extinguishers are charged. Bathrooms in the resident bedrooms were clean and operational and hot water measured 112.6 degrees Fahrenheit to 121.6 degrees Fahrenheit. Hot water temperature was set to 120.0 degrees Fahrenheit during the visit. Resident Bedrooms; LPAs inspected all resident rooms. Smoked detectors/Carbon Monoxide detectors tested operational. Pull cord signal system is operational. LPAs observed two rooms that were set up with model furnishings. All bedrooms had enough space to accommodate resident belongings. Resident rooms are unfurnished. LPA informed applicants that the facility is required to provide furniture to include, bed, night stand, lamp and chair, in good working order for residents who require it. Applicants stated they understood. All 4 Delayed egress exit doors in Memory Care are operational. Kitchen; LPA Jerome Haley inspected the kitchen. The refrigerator and freezer were operational and there were temperature logs posted on the refrigerator and freezer doors. Facility a has non-perishable food supply on hand as well as an emergency supply of food and water.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CLEARWATER AT NORTH TUSTIN
FACILITY NUMBER: 306006040
VISIT DATE: 11/22/2021
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Dining Room; is clean and organized and has enough space to accommodate the residents and is large enough to promote social distancing. Medication Room; LPAs observed the medication room is secured and in accessible to residents in care. Assisted Living and Memory each have their own medication room and medication carts to assist resident with the administration of medication. Exterior Grounds; LPAs inspected the exterior of the facility and there were no obstacles or hazardous. There were no bodies of water found. There was a main courtyard with shaded seating and dining areas, a BBQ area, and dog park. The exterior of the memory care also has shaded sitting areas. Fire Clearance: was approved by Santa Ana Fire Department Inspector Ryan Aloi on 11/17/21. Phone/Email: Facility phone number is 714.656-9200 email address is tammie.sampedro@clearwaterliving.com. Facility has submitted the emergency disaster plan and Covid-19 mitigation plan. Facility meets Title 22 Division 6 of the California Code of Regulations. Facility is ready for licensure. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was waived, applicants operate other licensed facilities that are in compliance. An exit interview was conducted and a copy of this report, LIC809 was explained and provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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