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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:45:55 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, 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
07/11/2022 and conducted by Evaluator Michelle Reed
COMPLAINT CONTROL NUMBER: 22-AS-20220711174604
FACILITY NAME:CLEARWATER AT NORTH TUSTINFACILITY NUMBER:
306006040
ADMINISTRATOR:JENNIFER KORNMANNFACILITY TYPE:
740
ADDRESS:11901 & 11905 NEWPORT AVENUETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:124CENSUS: 89DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jennifer KornmannTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident suffering a fall and sustaining an injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michelle Reed met with Adminsitrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The investigation consisted of interviews with Administrator, staff and witnesses as well as documentation from Resident #1's file. The following was determined:
Resident #1(R1) was admitted into the facility on April 22, 2022. R1 had Cognitive Impairment and according to records reviewed needed assistance with his activities of daily living. R1 was ambulatory and walked with a cane as he was unsteady. On July 8, 2022, at approximately 8:20pm Staff #1 found R1 on the floor of his apartment. R1 complained of head, knee and arm pain. 911 was immediately called. R1 was transported to the hospital. R1 sustained blunt trauma and returned to the facility using a wheelchair.
Based on the information gathered during the investigation, there was no supporting evidence of neglect or lack of supervision on the part of Clearwater staff that caused or contributed to R1’s fall. The allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Jennifer Kornmann and a copy of this report was provided.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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