<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 11/26/2025
Date Signed: 11/26/2025 04:16:48 PM

Document Has Been Signed on 11/26/2025 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 112DATE:
11/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Executive Director Jennifer KornmannTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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
On November 26, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Jennifer Kornmann was present and assisted on today's visit. LPA observed that Jennifer Kornmann has a valid Administrator certificate which expires on June 13, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and twenty four non-ambulatory residents, of which six may be bedridden, and has a hospice waiver for fifteen. 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 residents. Each building consist of resident apartments, with bathrooms located in suite, a dining hall, multiple activity rooms, multiple storage rooms, a wellness center, a beauty salon, a medication room, and staff offices. LPA, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPA observed the See Something, Say Something (PUB 475) poster mounted on the wall by the entryway of the facility. LPA inspected resident apartments in both assisted living and memory care. LPA observed resident apartments to be clear of any hazards. LPA observed resident apartments to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway closets. LPA inspected the bathrooms in each of the residents apartments and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 115.5 and 119.8 degrees Fahrenheit.
CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CLEARWATER AT NORTH TUSTIN
FACILITY NUMBER: 306006040
VISIT DATE: 11/26/2025
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
LPA inspected the commercial kitchen located in the assisted living building. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed knives and sharps to be inaccessible to residents. LPA observed the facility has a three day emergency food and water supply. LPA observed chemicals and toxins to be stored in a locked closet inaccessible to residents in care. LPA observed multiple fire extinguishers to be mounted on the walls in both buildings. Fire extinguishers were observed to be charged and serviced as of August 21, 2025. LPA observed the facility passed their most recent fire inspection visit conducted on October 21, 2025, which consisted of testing the smoke detectors, carbon monoxide detectors, and fire sprinklers. LPA observed the facility conducted their most recent emergency disaster drill on October 23, 2025. The facility has a medication room located in each building. The centrally stored medications are kept in locked medication carts in their respective buildings. LPA observed that First Aid kits are also stored in the medication rooms and they have all the required components. LPA inspected all other common areas such as the dining rooms, activity rooms, beauty salons, and wellness centers and observed them to be clear of any hazards.

LPA, accompanied by the ED, conducted a tour of the exterior portion of the facility. LPA observed the facility has an outdoor area for each buildings. LPA observed the outdoor areas for each building to be free of any hazards or obstructions. LPA observed shaded outdoor seating areas with furniture for resident use. There are no bodies of water on the premises.

LPA reviewed ten resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents’ medication and medication records. LPA reviewed ten staff files. LPA observed that Staff #3 (S3) did not complete the required twenty hours of annual training, and only had twelve hours of annual training documented for the year of 2024. All staff are background cleared and associated to the facility.

Based on today's observations, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with Executive Director Jennifer Kornmann. A copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/26/2025 04:16 PM - It Cannot Be Edited


Created By: Brandon Lopez On 11/26/2025 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLEARWATER AT NORTH TUSTIN
FACILITY NUMBER: 306006040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that Staff #3 (S3) did not complete the required twenty hours of annual training, and only had twelve hours of annual training documented for the year of 2024.
POC Due Date: 12/26/2025
Plan of Correction
1
2
3
4
The Executive Director stated that she will have S3 complete the required training hours. The Executive Director agreed to provide LPA proof of the comlpete training for S3 via email or fax by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4