306006040-11-1-2022-22-AS-SSAS-CKUW2J-20221104165426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:42:30 PM

Unfounded

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
08/17/2022 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20220817101613

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: 89	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jennifer Kornmann		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident wandered away from facility twice due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of this complaint investigation. Upon arrival, LPA met with Administrator Jennifer Kornmann. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined:

Anonymous Complainant alleges that unknown resident wandered away from the facility twice. No dates or times were provided as to when the alleged incidents took place. The facility was cited prior for elopements. It is unknown if this allegation is the same incidents.

This agency has investigated this complaint alleging that a resident wandered away due to lack of supervision from staff. We have found that the complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.An exit interview was conducted and a copy of this report was provided to Administrator Jennifer Kornmann.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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

LIC9099 (FAS) - (06/04)

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