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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:34:30 PM

Substantiated


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
08/23/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220823133542
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: 89DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer KornmannTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility does not have hot water
Residents are not being bathed
Residents laundry services are not being met while in care
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:

On 8/31/22, a tour of the Memory Care unit (Clearbrook) was conducted with Jennifer Kornmann. Hot water was tested in random resident rooms as well as the laundry room. Water temperatures were as follows:

Room 137 102 degrees F Room 152 108.3 degrees F
Room 130 100.4 degrees F Room 142 100.5 degrees F
Room 118A 104.3 degrees F Room 139 102 degrees F
Room 115 104.3 degrees F Laundry 106.8 degrees F
Room 112- 106.3 degrees F


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (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)
Page: 1 of 4
Control Number 22-AS-20220823133542
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: 11/01/2022
NARRATIVE
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Out of 9 rooms, 6 rooms did not have hot water that met regulation guidelines.

End of shift reports were reviewed and staff were interviewed. Shift reports for 8/24/22 -8/27/22 disclosed that Resident #1, #2, #3 ,#4 , #5 and #6, did not get their showers as there was no warm or hot water. Laundry services were also not completed during that time as there was no hot water.

Based upon water temperatures at the time of the 8/31/22 visit, interviews, and a review of records the preponderance of evidence standard has been met and the allegations are substantiated.

See LIC9099D for cited deficiencies.

An exit interview was conducted and a copy of this report and appeal rights were provided to Ms. Kornmann.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220823133542
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: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
87303(e)(2)
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Maintenance and Operation-Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degrees F.
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Licensee agrees to immediately check water temperatures on a daily basis to ensure that it is in between regulation guidelines. Certification will be provided. Further investigation by Maintenance after initial visit on 8/31/22 concluded that there were issues with the condenser and valve. All has been repaired.

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This requirement was not met as evidenced by: On 8/31/22 hot water temperatures were measured in random resident rooms and the laundry room. Out of 9 rooms, 6 rooms did not have hot water that met regulation guidelines. This poses an immediate health and safety risk to residents in care.
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Type A
11/02/2022
Section Cited
CCR
87464(f)(4)
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Basic Services-Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.This requirement not met as evidenced by:
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Licensee agrees to check hot water temperatures and end of shift reports to ensure that all residents are being showered as agreed to by the Licensee in the residents admission agreements and or care plans. Certification of understanding will be provided.
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End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22. Reports disclosed that Resident #1, #2, #3 ,#4, #5 and #6 did not receive their showers as there was no warm or hot water. This poses an immediate health and safety risk/ personal rights risk to residents in care
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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: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220823133542
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: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
87303(g)(1)
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Maintenance and Operation- Facilities which have washing machines shall:
Have adequate supplies available and equipment maintained in good repair.

This requirement was not met as evidenced by:
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Licensee agrees to check all end of shift reports as well as the hot water temperatures to ensure that all residents laundry is being completed as agreed to in the residents admission agreements and or care plans. Certification will be provided.


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End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22 and interviews were conducted with random staff. Laundry services were not completed due to no hot water.
This poses an immediate health and safety risk to residents in care.


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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: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4