306006040-7-7-2022-22-AS-AORZ-CJRVR3-20220930163916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 07/07/2022
Date Signed: 07/07/2022 06:40:14 PM

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
05/18/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220518102354

FACILITY NAME:	CLEARWATER AT NORTH TUSTIN		FACILITY NUMBER:	306006040
ADMINISTRATOR:	SAMPEDRO, TAMMIE		FACILITY TYPE:	740
ADDRESS:	11901 & 11905 NEWPORT AVENUE		TELEPHONE:	(714) 656-9200
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	124	CENSUS: 78	DATE:	07/07/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jennifer Kornmann - Executive Director		TIME COMPLETED:	06:50 PM

ALLEGATION(S):

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Facility doors are a hazard

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to investigate the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Jennifer Kornmann and explained the purpose of the visit.

On today's visit. LPA Velazquez conducted interviews with residents and staff. During the course of the investigation LPA Velazquez reviewed and obtained copies of facility, staff, and resident records. LPA also conducted interviews with residents and staff. The individuals interviewed provided conflicting statements and could not corroborate the allegation. The records reviewed included a proposal from Vortex dated May 25, 2022 for the delivery and installation of Quad 7000 Low Energy Door Operators that meet ADA guidelines, and staff email communication documenting the Vortex proposal and approval by staff. LPA also reviewed

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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 5

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
05/18/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220518102354

FACILITY NAME:	CLEARWATER AT NORTH TUSTIN		FACILITY NUMBER:	306006040
ADMINISTRATOR:	SAMPEDRO, TAMMIE		FACILITY TYPE:	740
ADDRESS:	11901 & 11905 NEWPORT AVENUE		TELEPHONE:	(714) 656-9200
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	124	CENSUS: 78	DATE:	07/07/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jennifer Kornmann - Executive Director		TIME COMPLETED:	06:50 PM

ALLEGATION(S):

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Staff are not providing adequate food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to investigate the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Jennifer Kornmann and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. During the course of the investigation LPA Velazquez reviewed and obtained copies of facility, staff, and resident records. LPA also conducted interviews with residents and staff. The records reviewed included culinary staff work schedules, direct care staff work schedules, facility meal menus for May, June, and July of 2022, invoices from The Party Staff Inc staffing agency that was utilized by the facility to hire temporary staff to fill in the gaps in staff coverage, July 2022 staff work schedules that documented continued need to utilize staffing agencies to cover

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20220518102354

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: 07/07/2022

NARRATIVE

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work shifts, resident and staff rosters. The current staffing agencies utilized by the facility are Concierge Senior Services and Angel Connection. LPA Velazquez also conducted interviews with staff and residents who were able to corroborate the allegation. Some staff indicated they assisted wherever they were needed and worked as dining room servers which was not their primary role in the facility. Other staff indicated they worked excessive hours due to the lack of staff present such as a dishwasher. Some residents indicated they had to wait an extended period of time for their meals or desserts to be served due to the lack of servers present. On one occasion a staff member indicated they were the only server to cover the dinner shift. Direct care staff known as Care Partners have their work schedules divided between providing care and supervision directly to residents and then are also scheduled to work as servers which is not their primary role in the facility. LPA Velazquez observed this Care Partner work as a server with their name badge clearly identifying them as a Care Partner. This Care Partner also indicated that on that particular day there was no one to cover their shift as a Care Partner which left the direct care staff understaffed. The resident records reviewed included Physician's Reports, Care Plans, Care Pricing which documented the levels of care and corresponding fees, North Tustin Health and Service Evaluation Results, and Admissions Agreements.

Based on the observations made, interviews which were conducted, and the records reviewed, the preponderance of evidence standard has been met, therefore the allegation of Staff are not providing adequate food service is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099 D.

An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the appeal rights, LIC 9098 and LIC 811s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20220518102354

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/28/2022 Section Cited CCR 87555(b)(18)	1 2 3 4 5 6 7	General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by: based on observation and interviews the licensee did not employ sufficient food service personnel which poses a potential risk to the health and safety of residents in care.	1 2 3 4 5 6 7	Licensee to ensure sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents at all times. Licensee to submit written proof of correction to LPA by POC due date indicating exactly how they will adhere to this regulation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20220518102354

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: 07/07/2022

NARRATIVE

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resident records which included Physician's Reports, North Tustin Health and Service Evaluation Results, and Admission Agreements. LPA Velazquez along with the Maintenance Director tested several doors throughout the facility that all meet ADA guidelines.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Facility doors are a hazard is deemed UNSUBSTANTIATED.

An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the LIC 811s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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