306006040-10-24-2022-22-AS-ETAA-CKHQ28-20221024114642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:46:50 AM

Document Has Been Signed on 10/24/2022 11:46 AM - 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 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: 84	DATE:	10/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Leo Serna, Jennifer Kornmann		TIME COMPLETED:	11:55 AM

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Business Office Director Leo Serna and stated the purpose of this visit. Executive Director Jennifer Kornmann was unable to attend the inspection.

The facility is a single-level structure divided into three zones, licensed for one hundred and twenty-four non-ambulatory residents with a hospice waiver for ten. Six may be bedridden. This facility offers Residential Care for the Elderly/Dementia.

At about 9:15 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. The facility is divided into 3 zones. Each zone has common areas which include, dining area, art studio, club room, hair salon, wellness center and some storage units. Resident rooms were selected at random for inspection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did have private restrooms. Resident restrooms were observed to be in good repair and provided with grab bars and hot water was measured between 105.0 degrees – 119.8 degrees Fahrenheit. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 poster posted in a prominent location. Kitchen was in good repair and in a separate room inaccessible to residents. LPA toured the kitchen and saw they had a walk-in refrigerator and freezer. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. Fire alarms and carbon monoxide alarms were previously tested and received as passing score on 09/23/2022. For the exterior portion, facility had an outside patio with shaded seating and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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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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
	VISIT DATE: 10/24/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Executive Director Jennifer Kornmann and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

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