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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 04/04/2022
Date Signed: 04/04/2022 04:05:44 PM


Document Has Been Signed on 04/04/2022 04:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CLEARWATER AT NORTH TUSTINFACILITY NUMBER:
306006040
ADMINISTRATOR:SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:11901 & 11905 NEWPORT AVENUETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:124CENSUS: 55DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tammie SampedroTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management. The visit was conducted to discuss two unusual incident reports sent to the Department on 3/17/22 and 3/28/22. Upon arrival, LPA met with Administrator Tammie Sampedro. A tour of the Clearbrook Building (Memory Care) was conducted and records were reviewed for Resident #1 and Resident #2.

On 3/10/22 R1 was admitted into the Community. According to records reviewed R1 resides in the Assisted Living Building. R1 cannot leave the facility unassisted and according to her care plan, has a history of wandering behavior. There was a wander guard put in place, but R1 took it off. On 3/11/22 at approximately 7:30 am, R1 was outside the front door trying to get back in to the building. The Concierge arrived for work and let her inside. At approximately 9:15am the Concierge received a call from the Sunrise Community down the street (quarter of a mile) that R1 was at their building trying to come inside. The police had been called and R1 was returned to the Community. On 3/12/22 R1 left the Community again, and the Maintenance Director brought her back. R1 was down the street from the building. He saw her down the street from the building on his way into work. R1 had also expressed wanting to hurt herself. R1 currently has a 1 on 1 caregiver and was seen by her doctor. R1 did not receive any injuries.

On 3/27/22 at approximately 5:45pm, R2 could not be found in the Memory Care building. A search of the building as well as the Assisted Living was conducted and law enforcement was contacted. R1 was found down the street in the area of Newport and 17th Street by staff and law enforcement and returned to the Community with no injuries. R1 was placed on frequent status checks.

See LIC809D for cited deficiencies.

An exit interview was conducted with Administrator Tammie Sampedro and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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Document Has Been Signed on 04/04/2022 04:05 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited

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Care of Person's With Dementia-Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.

This requirement was not met as evidenced by:
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R1 and R2 wandered from the Community without staff supervision. According to records reviewed they cannot leave the facility unassisted and have wandering behaviors.

This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
LIC809 (FAS) - (06/04)
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