306006040-3-22-2023-22-AS-SSAS-CQ789C-20230322221853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 03/22/2023
Date Signed: 03/22/2023 09:39:46 AM

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
07/08/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220708091818

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: 96	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jennifer Kornmann		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident suffered a fall resulting in serious injuries due to lack of care and supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Reed met with Administrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The complaint was investigated by the Department and consisted of interviews with Administrator, six of six staff, witnesses as well as documentation from the facility file. The following was determined:

Resident #1(R1) was admitted into the facility on January 3, 2022. R1 had Cognitive Impairment and according to records reviewed needed minimal assistance with his activities of daily living. R1 was not a fall risk at the time of admission, was ambulatory and had fallen three times within a two week period. The first two falls were unwitnessed. On June 17, 2022 R1 was found on the floor with a wound on the back of neck and the second on June 22, 2022. The second fall caused a wound on the back of his head and a skin tear. 911 was contacted and R1 was sent to the hospital for evaluation. He returned to the facility with fall precautions put into place.

On July 5, 2022 at approximately 11:45 am. Staff #1 witnessed R1 fall as he was entering his bedroom. Staff

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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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Control Number 22-AS-20220708091818

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: 03/22/2023

NARRATIVE

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took appropriate steps to assist R1 and call 911. R1 was transported to the hospital. R1 sustained a pelvic and left humorous fracture and a laceration at his left eye.

Based on the information gathered during the investigation, there was not definitive supporting evidence of neglect or lack of supervision on the part of Clearwater staff that caused or contributed to R1’s fall on July 5, 2022. The allegation is deemed 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 Administrator Kornmann and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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