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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 01/09/2025
Date Signed: 03/25/2025 10:44:36 AM

Document Has Been Signed on 03/25/2025 10:44 AM - It Cannot Be Edited

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/
DIRECTOR:		JENNIFER KORNMANNFACILITY TYPE:
740
ADDRESS:11901 & 11905 NEWPORT AVENUETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 124CENSUS: 107DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jennifer KornmannTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Eboni Bentley made an unannounced visit for the purpose of conducting a Required/Annual Inspection. Upon entry. LPAs were greeted by Concierge and explained the purpose of the inspection. LPAs met with Sales Manager Linda Robbins and further discussed the purpose of the inspection. Executive Director (ED) Jennifer Kornmann arrived at approximately 9:20 a.m.

During the inspection, LPAs and SM conducted a tour of the inside and outside of the facility, common areas, resident rooms, and observed the following:

The facility consists of two single-story buildings, the front building is used for assisted living residents and the back building is used for memory care. Each building has common areas which include, two dining areas, multiple activity rooms, a hair salon, and wellness center. Select resident rooms were inspected and all were observed to have the required furnishings. LPAs observed all resident beds had linens and blankets. Signal system was tested and observed to be operable. There are two courtyards with multiple shaded sitting areas. LPAs observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.0-123.6 degrees Fahrenheit; a Technical Violation was issued on this date.

LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers are located in every hallway and were observed to be fully charged with service tags dated August 15, 2024. Facility appliances were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. (Cont. LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 01/09/2025
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Medication was observed to be centrally stored and locked in a medication cart located within the medication room. LPAs reviewed centrally stored medication for select residents and did not observe any discrepancies. LPAs reviewed ten resident files and nine staff files. LPA interviewed ten residents and five staff.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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