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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:42:03 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
08/11/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220811134259
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: 95DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennifer KornmannTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
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9
Resident sustained multiple falls while in care due to lack of supervision
INVESTIGATION FINDINGS:
1
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8
9
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13
Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Administrator Jennifer Kornmann. The complaint was investigated and consisted of interviews with the facility staff, Administrator, and a review of Resident #1’s records. The following was determined:

Resident #1 (R1) was admitted into the facility on 12/3/21. R1 resided in the Assisted Living building.
On 8/11/22, at approximately 6:15am, R1 had an unwitnessed fall in his room. Staff immediately called 911 and R1 was taken to the hospital for evaluation. R1 did not receive any injuries. Records reviewed disclosed that R1 had a series of falls prior to 8/11.

Based upon the interviews conducted and the records reviewed, 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 R1’s falls were due to lack of supervision. An exit interview was conducted and a copy of this report was provided to Jennifer Kornmann.
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: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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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