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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:20:23 PM


Document Has Been Signed on 07/12/2022 03:20 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:JENNIFER KORNMANNFACILITY TYPE:
740
ADDRESS:11901 & 11905 NEWPORT AVENUETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:124CENSUS: 78DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jennifer KornmannTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Michelle Reed conducted an unannounced Case Management visit to the facility. LPA met with Administrator Jennifer Kornmann to follow up on an Exemption Denial for Staff #1.

On 3/26/22, the Department issued an Exemption Denial for Staff #1. On 3/28/22 Executive Director Tammy Sampedro signed and sent the Confirmation of Removal letter to the Department indicating that Staff #1 had been removed from the facility.

Today, 7/12/22, Executive Director Jennifer Kornmann informed LPA that Staff #1 was still working at the facility. Ms. Kornmann immediately sent Staff #1 home upon her arrival to work. It is unknown at this time if an appeal was filed. S1 is no longer associated to the facility.

No citations at this time pending further information.

An exit interview was conducted and a copy of this report was given to
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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