306006040-2-24-2023-22-AS-SSAS-CPH3DU-20230228171006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:07:20 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230221154905

FACILITY NAME:	CLEARWATER AT NORTH TUSTIN		FACILITY NUMBER:	306006040
ADMINISTRATOR:	JENNIFER KORNMANN		FACILITY TYPE:	740
ADDRESS:	11901 & 11905 NEWPORT AVENUE		TELEPHONE:	(714) 656-9200
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	124	CENSUS: 94	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Jennifer Kornmann, Executive Director		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide resident's authorized representative with all records.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jessica Cho made an unannounced complaint visit for the purpose to investigate into the above allegation. LPA met with Executive Director (ED) Jennifer Kornmann upon arrival and stated the purpose of the visit. During the course of the investigation, LPA completed a file review, obtained records for Resident 1 (R1), and interviewed the ED. The following are the findings which involved record review and interview:

On the allegation that staff did not provide resident's authorized representative with all records, it was alleged that R1's progress notes for the first two months were not provided upon request. R1 was admitted on 04/29/2022 and departed from the facility on 08/25/2022. ED stated per interview that copies of records for R1 were picked up at the facility by the authorized representative on January 26, 2023. LPA observed per review of records that the progress notes started on 06/23/2022 and ended on 08/26/2022. LPA along with the ED reviewed the Yardi database system on the ED's computer which contains all...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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 2

Control Number 22-AS-20230221154905

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

digitized progress notes and verified that the facility did not have progress notes entered from 04/29/2022 to 06/22/2022. Therefore, the facility provided all progress notes that were available to the authorized representative.

This agency has investigated the complaint and based on the observations made, interview that was conducted and the records reviewed, the above allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Executive Director Jennifer Kornmann, and a copy of this report and the LIC811 were provided during this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2