306006401-11-21-2025-22-AS-LMOA-DPHVBZ-20251219151823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006401
Report Date: 11/21/2025
Date Signed: 11/21/2025 03:27:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/07/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250207150705

FACILITY NAME:	CLEARWATER NEWPORT BEACH		FACILITY NUMBER:	306006401
ADMINISTRATOR:	JOHNSTON, ROBERT		FACILITY TYPE:	740
ADDRESS:	101 BAYVIEW PLACE		TELEPHONE:	(949) 942-6391
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY:	120	CENSUS: 83	DATE:	11/21/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Executive Director- Kathleen Olson		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff did not assess resident's medical condition and need appropriately.

INVESTIGATION FINDINGS:

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On November 21, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Kathleen Olson

The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of a resident’s service records which include Physician’s Report, Appraisal Needs and Services Plans, Identification and Emergency information, admission agreement, facility progress notes, and other document records. LPA conducted interviews with seven staff.

The investigation revealed the following:

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

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 3

Control Number 22-AS-20250207150705

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLEARWATER NEWPORT BEACH	FACILITY NUMBER: 306006401
	VISIT DATE: 11/21/2025

NARRATIVE

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Allegation: Facility staff did not assess resident's medical condition and need appropriately.
It is alleged an altercation between resident and staff occurred. It is alleged the resident was not aggressive during this time and was sent to the hospital. No communication was provided to the resident’s responsible party prior to the incident and why the resident was sent to the hospital.

Based on record review, resident #1 (R1) has a history of being physically and verbally aggressive with staff. Admission Agreement was signed and dated October 15, 2024, which was the same day R1 was admitted to the facility. Physician’s report dated October 8, 2024, R1 was diagnosed with dementia and has concerns with confusion and sun downing behavior. Facility progress notes for the incident dated January 5, 2025, stated medication technician responded to a request from staff in regard to R1. Medication technician arrived to assist the staff because R1 entered another resident’s room. Staff tried to redirect R1 away from the room, but R1 would kick, punch, and twist the staff’s hand. It is noted that R1 was transported to a hospital due to being aggressive with staff.

Prior to R1 leaving the facility, another facility progress note entry from January 5, 2025, stated S3 reached out to the resident’s responsible party to inform them that R1 needed to be sent out to the hospital because of their behaviors. It is noted the responsible party agreed to S3’s assessment. The facility progress notes also stated that R1 was physically and verbally aggressive with staff while R1 was being escorted to the emergency services unit. Emergency Service (EMS) record dated January 5, 2025, revealed that EMS arrived at 1:59 PM due to R1’s violent behavior and left the scene at 2:24 PM. The resident was admitted to the hospital on January 5, 2025, at 2:45PM, for restlessness, agitation, and personal history of other mental and behavioral disorders. Hospital records on page 2 stated R1 was admitted to the Hospital’s Brain Spine unit on January 13, 2025.

Preplacement Appraisal Needs and Service plan dated October 1, 2024, stated R1 had severe confusion or forgetfulness, and moderate aggressive behavior. R1’s service plan with the last assessment dated on November 19, 2024, stated R1 has current or history of occasional disruptive, aggressive, or socially inappropriate behavior. It also notes R1 may require special tolerance or staff training. R1’s Service Plan with an assessment date of December 27, 2024, stated R1 is verbally or physically inappropriate, and requires supervision such as a professionally authorized behavioral management program. Facility progress notes dated December 5, 2024, R1 was aggressive with staff by kicking and punching care staff as they attempted to help R1 shower.
Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250207150705

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLEARWATER NEWPORT BEACH	FACILITY NUMBER: 306006401
	VISIT DATE: 11/21/2025

NARRATIVE

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Facility Progress notes dated December 8, 2025, R1 was aggressive to care staff by grabbing them and then turned a table over and a TV over. Facility progress noted dated January 4, 2025, R1 came out of a care room in need to use the bathroom. Staff noted the care room had remnants of bowel movement on the carpet and trash can. Staff attempted to wash up R1 for hygiene and dignity, which led to R1 being upset because R1 wanted to leave the bathroom. While staff attempted to clean up R1, R1 kicked, punched, scratched, yelled, and attempted to bite the staff. The facility assessed R1’s medical conditions as conditions changed and applied the service plans to meet R1’s needs.

Based on interviews conducted seven out seven staff denied the allegation. One out of one witness confirmed the allegation. All staff stated they were aware of R1’s medical conditions. All staff logged in their incidents and presented it to the Memory Support Director and/or any other supervisor what was going on. All staff stated they followed protocol in redirecting, assisting, or caring for R1, when R1 exhibited aggressive behavior. They all stated they were given updates with R1 with procedures, protocol, and how to proceed. Based on interviews conducted with S4, S6, and S7, they attempted to redirect R1 out of another resident’s room on January 5, 2025, but this led R1 to be aggressive with them by kicking, punching, and twisting their arms. They all confirmed that R1 was sent to the hospital on January 5, 2025.

Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all staff denied that the facility staff did not assess resident’s medication and need appropriately. The facility kept a record of whenever R1’s condition changed.

Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegation facility staff did not assess resident's medical condition and need appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted and a copy of the report and LIC811 were provided to Executive Director Kathleen Olson.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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