306006040-1-7-2026-22-AS-APAO-DQCPQT-20260115103138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 01/07/2026
Date Signed: 01/07/2026 03:45:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/28/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240528112916

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: 112	DATE:	01/07/2026
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Jennifer Kornmann-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff neglect led to resident sustaining pressure injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on May 28, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jennifer Kornmann. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that staff neglect led to resident sustaining pressure injuries. Regarding the allegation the following was revealed: During a follow up visit on May 16, 2024, the Primary Care Physician (PCP) for R1 noticed skin breakdown to right hip. On May 16, 2024, PCP ordered Wound Care. During the course of the interviews with the PCP, the PCP stated that in May he noticed a shallow hip and requested Home Health care for a Pressure Injury 2. Per PCP, the pressure injury was not due to neglect. During the investigation LPA reviewed the Physical and Occupational therapy visits dated April and May 2024 for R1. Per email dated May 17, 2024, the PCP ordered an egg cushion for bed and sheepskin for chair to help alleviate pressure on hip.
CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 22-AS-20240528112916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/07/2026

NARRATIVE

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During the course of the interviews with staff, Staff 3 (S3) reported that R1 is repositioned every two hours and stated that R1 favored positioning back to his right side. Per S4, R1 did not develop a pressure injury due to staff neglect. S5 stated that R1 did not develop pressure injuries due to lack of care or staff neglect.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with AD Kornmann, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/28/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240528112916

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: 112	DATE:	01/07/2026
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Jennifer Kornmann-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not meet resident's medical needs
Staff did not allowed resident access to telephone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on May 28, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jennifer Kornmann. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that staff did not meet resident's medical needs. Regarding the allegation the following was revealed: During the investigation LPA reviewed documents including the Clearwater at North Tustin progress notes dated October 24, 2023, for Resident 1 (R1). Per progress notes, it states Doctor removed staples from wound on top of head. Per progress notes, resident tolerated well, daughter and Power of Attorney ( POA) notified. During the course of the interviews with residents, R1 reported that staff are helpful. During the course of the interviews with staff, Staff 5 (S5) reported that the Primary Care Physician (PCP) came to the facility and removed the staples for R1. During the course of the interviews with witnesses, Witness 1 (W1) stated that the staples were removed timely.

CONTINUED ON LIC9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 22-AS-20240528112916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/07/2026

NARRATIVE

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Per W1, he always sees staff working hard.

Regarding the allegation that staff did not allowed resident access to telephone, the following was revealed: During the investigation LPA reviewed documents including the Clearwater at North Tustin Admission Agreement dated October 28, 2022, for R1. Per Admission Agreement, under Statement of Residents' Personal Rights it states residents to have reasonable access to telephones, to both make and receive confidential calls. During the course of the interviews with residents, R1 reported that he can use the telephone at anytime. During the course of the interviews with staff, S1 through S5 reported that staff always pass the telephone calls to the residents and/or stated that the residents always have access to the telephone. Regarding the statement that facility is understaffed, LPA reviewed documents including the Clearwater at North Tustin staff schedule dated May 2024. Per staff schedule, on average there are four Caregivers and one Medication Technician (MT) for the morning and evening shifts and two Caregivers and one MT for the night shift for 32 residents in care.

Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis.

LPA Ramirez conducted an exit interview and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/28/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240528112916

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: 112	DATE:	01/07/2026
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Jennifer Kornmann-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not meet resident's diapering needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on May 28, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jennifer Kornmann. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that staff did not meet resident's diapering needs. Regarding the allegation the following was revealed: During the investigation LPA reviewed documents including the Clearwater at North Tustin assignments dated February 2024 and April 2024. Per assignment schedule, Resident 1 (R1) was assisted with incontinence care two times during the morning, evening and night shifts. During the course of the interviews with residents, R1 reported that he does not need assistance with incontinent care. During the course of the interviews with staff, Staff 1 (S1) through S5 reported that they have never seen a resident being left in a soaked diaper and/or stated that the diapers get changed every two to three hours or as needed.
CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 22-AS-20240528112916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/07/2026

NARRATIVE

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Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with AD Kornmann, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6