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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 08/08/2022
Date Signed: 08/08/2022 01:01:29 PM


Document Has Been Signed on 08/08/2022 01:01 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: DATE:
08/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer KornmannTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Michelle Reed arrived at the facility to conduct a case management visit. The visit was conducted to discuss an Unusual Incident that was reported to Licensing on 8/4/22. Upon arrival, LPA met Business Office Manager Leo Serna. Administrator Jennifer Kornmann arrived at approximately 9:30am.

On 8/4/22 at approximately 2:50pm, Resident #1(R1's) exited the side door of the Memory Care Unit. Staff was unaware that she had exited. Staff were alerted by R1's responsible party when he arrived to take R1 to a medical appointment a little after 3pm. Upon notice, staff immediately began a search of the property and surrounding area. R1 was found at approximately 3:20pm by the Culinary Food Service Director. R1 was found 6 blocks away from the facility at Newport Ave and Foothill Blvd. R1 did not have any injuries and was taken to her medical appointment by her responsible party.

This is not the first time R1 has left the facility, there have been 2 other elopements. The first was on 3/27/22 and the second on 7/24/22. All three elopements involved the delayed egress doors. During the second elopement R1 did not leave the property and was found outside by staff in the parking lot,

According to Ms. Kornmann, there is a little bit of a delay for the doors to lock once the key pad is set. Camera's present did show R1 exiting the doors during the delay. Staff have been trained and reminded to ensure that the doors are secure before they walk away. There are also signs at the doors to remind staff to check the doors. At the time of this visit, LPA toured the Clearbrook Building (Memory Care). Delayed egress doors were operating and R1 was observed with a 1:1 care staff. Interviews were also conducted and records reviewed for R1.

See LIC809D for cited deficiencies. An exit interview was conducted with Administrator Jennifer Kornmann 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: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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 08/08/2022 01:01 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: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
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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On 8/4/22 R1 eloped from the Community via the delayed egress doors in the Memory Care Unit(Clearbrook). Staff were unaware that R1 had left the Community. This was not the first elopement through the doors by R1. R1 also eloped on 3/27/22 and 7/24/22.
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violation within a 12 month period and civil penalties are assessed.

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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: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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