Clearwater at South Bay

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure resident's hygiene needs were met Staff locked resident out of bedroom Staff left resident on the floor for an extended period of time Staff did not allow resident to have a visitor Staff confined resident to bedroom Staff do not treat residents with dignity and respect.

On 08/18/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Diane ‘Dee’ Navarro, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation revealed the following: During the initial visit conducted on 06/25/2026, LPA inspected the facility, interviewed Staff S1-S7, interviewed Residents R1-R12, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Admission Agreement (dated 02/11/2026), Needs and Service Plan, Power of Attorney documents, Health Information Release Authorization (dated 08/11/2025), Request to Restrict Use or Disclosure of Health Information (dated 08/11/2025), SafelyYou Program Resident Consent (dated 02/05/2025), Torrance Police Department incident card from 06/12/2026, Preplacement Appraisal Information (dated 08/11/2025), Notes & Incidents from 02/022026 through 06/20/2026, Emails between the facility and the Power of Attorney (POA), and business card for R1’s Court Appointed Attorney of Law. The investigation revealed the following: Unsubstantiated Allegation: Staff did not ensure resident’s hygiene needs were met The allegation alleges a resident’s hygiene has become poor due to staff not allowing a resident to wash their face or brush their teeth. During the facility inspection, LPA observed Staff assisting Residents with activities of daily living, including ambulating, toileting and incontinent care, dressing and changing, grooming, and bathing. During record review, LPA received and reviewed the Residence and Care Agreement, signed and dated 01/13/2026, and observed on page 5 under, II. Personal Assistance and Care states “In accordance with your plan of care and applicable California law, we will provide you assistance, as needed, with activities of daily living, such as bathing, dressing, ambulating, and assistance with medications.” LPA received and reviewed the Service Plan, dated 02/06/2026, for Resident R1 that indicates R1 requires full assistance with bathing, dressing, grooming, medications, and ambulating. LPA observed R1 requires standby assistance with oral care, toileting, and transfers. During interviews with Staff S1-S7, were asked how much time they allow to assist a resident with hygiene needs, seven (7) out of seven (7) stated the residents takes as long as they need. During interviews with Residents R1-R12, were asked if staff allow them time to perform hygiene tasks, twelve (12) out of twelve (12) stated they take as long as they need. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff locked resident out of bedroom The allegation alleges that when a resident leaves their room in the morning, staff lock their door for hours. During the facility inspection, LPA observed some doors were locked and closed and others were unlocked and/or open. LPA observed residents being escorted by staff to and from their rooms. During interviews with residents, LPA observed residents have their own room key on a band around their wrist or on a string around their necks. During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement Appendix A-Schedule of Fees for Additional Item and Services, signed and dated 01/13/2026, that indicates a fee will be charged for any lost room keys and fee will be charged for re-keying of apartment due to lost keys. Additionally, in the Resident Handbook signed and dated 01/13/2026, on page 15, under Security, states “Keep you door locked when away from home.” During interviews with Staff S1-S7, were asked if they lock residents out of their room during the day, seven (7) out of seven (7) stated no, they do not lock resident’s out of their rooms. During interviews with Residents R1-R12, were asked if there was a time staff locked them out of their room, twelve (12) out of twelve (12) stated no, staff have not locked them out of their room. Additionally, twelve (12) out of twelve (12) residents showed they have a key to their rooms. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff left resident on the floor for an extended period of time The allegation alleges that a resident experienced a fall, and staff did not find them for an extended period of time. During the facility inspection, LPA observed caregivers going to resident’s rooms, knocking, asking if they can come in, and once in they asked the resident if they require or need anything. During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated on 01/13/2026, that states on page 2 “We encourage our residents to participate in physical activities to the extent of their capabilities. Thus, falls and other personal injuries may occur from time to time.” LPA received and reviewed SafelyYou Program Resident Consent, signed and dated 02/05/2025, that states on page 1, “SafelyYou utilizes artificial intelligence (AI) software and electronic monitoring hardware to detect falls, identify health and safety risks, and detect care delivery pattern.” Additionally, it states “ The SafelyYou system does not have perfect accuracy and may experience periods of downtime or system interruptions.” LPA received and reviewed Resident R1’s Service Plan, signed and dated 02/06/2026, and observed R1 receives full assistance with transfers and mobility as fall precautions. LPA received and reviewed Resident R1’s Notes and Incidents-Resident Summary LPA observed on 02/15/2026, Resident R1 experienced two (2) falls. On 02/15/2026 at 12:29am, staff received a notification from SafelyYou indicating R1 experienced a fall. Upon review of the footage, R1 tried to get up out of bed and lost their balance, and fell after refusing incontinent assistance from staff. The second incident occurred on 02/15/2026 at 3:22am, staff received notification from SafelyYou indicated R1 experienced a fall. Upon review of the footage, R1 stood up getting out of bed, began walking towards walker and lost their balance. LPA observed R1 experienced an additional fall on 04/14/2026 at 8:39am. R1 was found on the floor next to their bed by caregiver. Resident R1 did not complain of any pain or discomfort and no visible injuries. R1 was agitated that they were on the floor. During interviews with Staff S1-S7, were asked if there was a time a resident was found on the ground for an extended period of time, seven (7) out of seven (7) stated no, a resident has not been left on the ground for an extended period of time. During interviews with Residents R1-R12, were asked if they experienced an emergency and did not receive assistance for an extended period of time, twelve (12) out of twelve (12) stated no, they have not been left on the floor for an extended period of time. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not allow resident to have a visitor The allegation alleges staff are not allowing a resident to have specific visitors per the power of attorney’s request. During the facility inspection, LPA observed resident visitors coming into the facility, checking in at the front desk, and going to the area of the facility their family was in. During record review, LPA received and reviewed Resident R1’s Notes and Incidents-Resident Summary that states on 06/17/2026, R1’s POA met with S1 and Memory Support Director, to discuss the incident that occurred on 06/12/2026 with a family member. R1’s POA was made aware the community placed a no trespass notice for the family member after the disruption and screaming and yelling in front of other residents resulting in staff having to call 911. LPA received the Torrance Police Department incident card, 260022933, for their call out on 06/12/2026 when they were called to assist with having a visitor for Resident R1 removed from the facility due to disruptive behavior. LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated 01/13/2026, and observed on page 20, under F. Guests Visits and Communications that states “Your guests are welcome to visit…provided they respect the rights of other residents and staff and abide by our visitor and guest policies…” Additionally on page 21 it states, “You will be responsible for assuring that your guests abide by these rules and are not disruptive.” Additionally, LPA observed on page 21 it states, “We reserve the right to remove or deny entry to Clearwater at South Bay to any visitor whom we determine disruptive or dangerous.” LPA received and reviewed Resident R1’s Admission Agreement Appendix G-Statement of Resident’s Personal Rights, signed and dated 01/13/2026, that states on page 2 residents have the right “to consent to have their relative and other individuasl of their choosing visit during reasonable hours, privately, and without prior notice.” During interviews with Staff S1-S7, were asked if they have denied a resident’s visitor, seven (7) out of seven (7) stated no, they have not denied a resident’s visitor unless there is a court order, no trespass order, or the conservator has the authority to make that decision. During interviews with Residents R1-R12, were asked if staff have denied a visitor, eleven (11) out of twelve (12) stated no, staff have not denied their visitors. One (1) out of twelve (12) stated yes, staff have denied a visitor due to their visitor’s actions at the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff confined resident to bedroom The allegation alleges staff locked a resident in their room. During the facility inspection, LPA observed residents in common areas watching television, talking with other residents or staff, and participating in activities and exercise. LPA tested resident rooms, by having staff lock the door from the outside, and the LPA was able to easily exit by pushing down on the door handle. During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement, signed and dated 01/13/2026, that states on page 1, “Clearwater at South Bay is not permitted to use restraints on its residents, and the use of restraints is also inconsistent with our philosophy.” LPA received and reviewed Admission Agreement Appendix G-Statement of Resident’s Personal Right, that states resident have the right “to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night." LPA received and reviewed Resident R1’ Service Plan, dated and signed 02/06/2026, that indicates in the Psycho-Social Engagement, R1 is “actively involved in community life.” During interviews with Staff S1-S7, were asked if they have confined a resident to their room, seven (7) out of seven (7) stated no, they have not confined a resident to their room. During interviews with Residents R1-R12, were asked if there was a time they were confined to their room, twelve (12) out of twelve (12) state no, they have not been confined to their room. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff do not treat residents with dignity and respect The allegation alleges staff are instructed to follow a resident while in the facility causing the resident to feel uncomfortable. During the facility inspection, LPA observed staff escorting residents to their rooms, activities, and meals. During record review, LPA received and reviewed Resident R1’s Residence and Care Agreement Appendix G-Statement of Residents’ Personal Rights, that states “Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff, residents, and other persons. LPA received and reviewed Resident R1’s Service Plan, which indicates under Mobility, R1 needs full assistance that includes escorting to meals and activities to ensure overall wellbeing. During interviews with Staff S1-S7, were asked how they treat residents with respect and dignity, seven (7) out of seven (7) stated they listen to their wants and need and respect their privacy. During interviews with Residents R1-R12, were asked if staff treat them with respect and dignity, twelve (12) out of twelve (12) stated yes, staff treat them with respect and dignity. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Diane ‘Dee' Navarro, Memory Support Lifestyle Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 11-AS-20260618083343

Allegation investigated: Staff did not prevent resident from sustaining wounds. Staff did not ensure resident was repositioned as needed. Staff did not ensure resident's care plan was followed.

On 08/12/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with Executive Director Diane Navarro. Investigation consisted of the following: On 08/11/2026, the Department obtained Personnel Record, Register of Residents, and Residents #1 - #4 Records. LPA interviewed Staff #1 – 9 (S1 – S9) and Witness #1 (W1). On 08/12/2026, the Department obtained Resident #3’s Face Sheet. LPA interviewed Staff #10 - #11 (S10 - S11), Resident #2 - #8 (R2 – R8) and Witnesses #2 - #3 (W2 – W3). Note: Resident #1 passed away in 05/2026. Resident #3 did not respond to questions. Resident #9 - #10 were unavailable for interviews. Investigation revealed the following: Allegation: Staff did not prevent resident from sustaining wounds. It is alleged Resident #1 (R1) developed two bedsores seven months ago. Continue to LIC9099-C. Unsubstantiated Record review revealed the following: Review of Physician’s Report (12/11/24) does not reveal a history of skin breakdown. R1 can transfer independently but for the purpose of fire clearance, R1 is nonambulatory. R1’s secondary diagnosis is dementia. Review of Needs and Services Plan (08/11/25) revealed R1 would receive support for safe ambulation, mobility and repositioning. Review of Torrance Memorial Medical Center (01/27/26) revealed R1 went to the hospital for nausea, vomiting, cancer, and weakness. Review of Hospice Initiation revealed R1 started hospice on 02/19/26. Review of Hospice Healthcare plan (ordered 03/10/26) revealed R1 had a stage 2 pressure injury to sacroccyx. A wound care specialist was ordered (03/17/26) for wound consult. Review of Outside Agency (Hospice) Documentation (03/19/26) revealed R1 was seen for wound care evaluation and treatment. Review of Outside Agency (Hospice) Documentation (04/04/26) revealed R1’s wound dressed on sacrococcyx and healing. Review of Physician’s Report (05/19/26) revealed R1 has a history of skin breakdown (sacrococcyx unstageable) and requires continuous bed care. R1 cannot independently transfer to and from bed. R1 is bedridden. Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 did not have a pressure injury at admissions (02/19/26). R1’s skin was clear and intake. R1 was referred to a wound care specialist on 03/17/26 and the first visit was on 03/19/26. R1 would receive wound care services weekly or as needed. Upon readmission (04/24/26), R1 did not have an open wound. Witness #2 (W2), Private Caregiver, indicated Resident #8 has not developed any bed sores or wounds. Witness #3 ((W3), Power of Attorney to Resident #3, indicated R3 recently developed a wound but it is R3’s fault because R3 refuses to move. Staff #6 (S6) indicated R1 had a little skin breakdown, nothing massive, towards the end of life. S6 indicated R1 was repositioned before every change. Staff #8 (S8) does not recall R1 having a wound prior to hospice. Staff #9 (S9) indicated R1 did not have a wound but redness prior to hospice. Six out of six resident interviews (R2, R4 – R8) indicated they have not developed any wounds since living at the facility. Observations revealed the following: LPA observed R3, R5, R8 in hospital bed and R4 and R6 in wheelchairs. Regarding the allegation, “Staff did not prevent resident from sustaining wounds,” based on record review, interviews, and observations, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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 allegation is unsubstantiated. Continue to LIC9099-C. Allegation: Staff did not ensure resident was repositioned as needed Record review revealed the following: Review of Needs and Services Plan (08/11/25) revealed R1 would receive support for safe ambulation, mobility and repositioning. Review of Physician’s Report (05/19/26) revealed R1 has a history of skin breakdown and requires continuous bed care. Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 should be repositioned every two hours or as needed. Witness #2 (W2), Private Caregiver, indicated Resident #8 is repositioned every 2 – 3 hours. Witness #3 ((W3), Power of Attorney to Resident #3, indicated staff repositions R3 all of the time. Seven out of seven staff interviews (S2 - S6, S8 - S9) indicated residents are repositioned every two hours. Three resident interviews (R2, R4, R7,) indicated they do not need assistance with repositioning. Three resident interviews (R5 – R6, R8) indicated staff assists with repositioning. Observations revealed the following: LPA observed R3, R5, R8 in hospital bed and R4 and R6 in wheelchairs. Regarding the allegation, “Staff did not ensure resident was repositioned as needed,” based on record review, interviews, and observations, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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 allegation is unsubstantiated. Allegation: Staff did not ensure resident's care plan was followed It is alleged Resident #1 (R1) choked while eating because staff did not monitor R1 while eating. Record review revealed the following: Review of Physician’s Report (05/19/26) revealed R1 is unable to feed self and special diet needs are thickened liquids and pureed. Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 was on a pureed diet but on 04/29/26, it was changed by a family member to a mechanical soft diet. Witness #2 (W2), Private Caregiver, indicated W2 feeds Resident #8. Witness #3 ((W3), Power of Attorney to Resident #3, indicated R3 can feed self and staff ensures that food is finely chopped up. W3 indicated R3 has not had a chocking incident. Interview with Executive Director (S1) indicated R1 did not pass away from chocking but R1 was on hospice and passed away around 3:40 PM on 05/22/26. Interview with Staff #6 (S6) indicated S6 had repositioned and changed R1 prior to R1’s passing. R1 was not eating prior to passing away. Continue to LIC9099-C. S6 indicated S9 went to R1’s room to find out what R1 wanted for dinner and found R1 unresponsive. Interview with Staff #9 (S9) indicated finding R1 unresponsive in bed. S9 indicated R1 did not have any food near the time of death. S9 indicated R1 could not swallow and was not eating. Staff #10 indicated dinner is served around 4:00 PM. Three resident (R2, R4, R7) indicated they can independently feed themselves. Three resident interviews (R5 – R6, R8) indicated staff assist with feeding. Regarding the allegation, “Staff did not ensure resident's care plan was followed,” based on record review and interviews, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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 allegation is unsubstantiated. An exit interview was conducted, technical assistance provided, and a hard copy was provided to the Executive Director Diane Navarro.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 11-AS-20260805154446

Allegation investigated: Staff gave expired medication to resident in care

On 07/31/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Krista Solomon, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA inspected the facility, reviewed ten (10) residents Centrally Stored Medications, interviewed Staff S1 and S7, and interviewed Residents R2-R12. During the initial visit conducted on 06/17/2026, LPA interviewed Staff S2-S6 and received and reviewed pertinent documents to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Physician’s Orders, Medication Administration Record (MAR), Centrally stored medications, and Medication Sign-In and Medication Sign-Out. The investigation consisted of the following: Unsubstantiated Allegation: Staff gave expired medication to resident in care The allegation alleges a resident was provided an expired medication. During a medication review, LPA reviewed the Centrally Stored Medications for ten (10) residents and observed ten (10) out of ten (10) residents’ medications were not expired. During record review, LPA received and reviewed R1’s Preplacement Appraisal Information (dated 04/29/2026) that lists Trazadone under medications taking. LPA observed on the Centrally Stored Medication & Destruction Records (dated 05/11/2026) for R1 did not list Trazadone. LPA received and reviewed the Physician Report and Admission Orders (dated 05/04/2026) and did not observe Trazadone listed on the Admission Orders. LPA observed on the Notes and Incidents Log, dated 05/14/2026, staff contacted R1'sPrimary Care Physician to request an order for Trazdone. LPA received and reviewed a Prescription slip date 05/15/2026 for Trazodone. LPA reviewed the eMAR for R1 and observed R1 received Trazodone from 05/16/2026 through 06/07/2026. During interviews with Staff S1-S7, were asked if a resident has been given and expired medication, seven (7) out of seven (7) stated no, to their knowledge no resident has been given expired medication. Additionally, Staff S1-S7 were asked how often medications are checked if they are expired, seven (7) out of seven (7) a monthly audit is conducted to review all medications expiration date. During interviews with Residents R2-R12, were asked if they have been given expired medication, eleven (11) out of eleven (11) stated no, they have not been given expired medication. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Rhonda Madrid, Sales Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 11-AS-20260610100831

Allegation investigated: Licensee did not abide by the admission agreement

On 02/12/2026, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Complaint Visit to the facility listed above. LPA met with Apolinario ‘Paul’ Gozon, Executive Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Staff S4 and S5, interviewed Residents R1-R12 and received and reviewed Resident R1 and R2’s Physician Report, and email communictaions. During the initial visit conducted on 12/23/2025, LPA inspected the facility, interviewed Staff S1-S3, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Resident Roster, Residence and Care Agreement Admission Agreement, billing Statement for December 1, 2025, Move-In Prorate Worksheet dated 09/30/2025, Community Fee Receipt dated 09/30/2025, and emails and texts regarding billing concerns. The investigation revealed the following: Unsubstantiated Allegation: Licensee did not abide by the admission agreement The allegation alleges that the licensee did not abide by the admission agreement by not disclosing all fees and charges. During record review, LPA received and reviewed residents R1 and R2’s Residence and Care Agreement, signed and dated 10/01/2025 by R1, that states “This Agreement shall be effective as of 09/30/2025.” Additionally, LPA received and reviewed the Move-In Prorate Worksheet -AL/MS signed and dated on 09/30/2025 by R1, that indicates R1 and R2 were prorated for September 2025 and was charged for one (1) day. During interviews with Staff S1-S5, they were asked if the move-in incentive and billing is explained to potential or new residents, five (5) out of five (5) stated it is explained and broken down based on the selected apartment, services they sign up for, and level of assistance required. Additionally, Staff S1-S5 were asked if fees and conditions are listed on the Admission Agreements, five (5) out of five (5) stated yes, fees and conditions are listed in the Residence and Care Agreement. During interviews with Residents R1-R12, they were asked if they were offered an incentive when they moved in and if the incentive was honored, five (5) out of twelve (12) stated yes, they were offered an incentive to move in, and it was honored. Three (3) out of twelve (12) indicated no they were not offered an incentive, or they were not sure. Four (4) out of twelve (12) declined to be interviewed. Resident R1-R12 were additionally asked if the pricing for lodging, assistance, and services were explained to them and listed in the Residence and Care Agreement, eight (8) out of twelve (12) stated yes it was explained to them, and it is listed. Four (4) out of twelve (12) declined to be interviewed. Additionally, during interviews with Residents R1-R12, they were asked if they have been charged a fee or service charge for a service they did not receive, eight (8) out of twelve (12) stated they have not been over charged. Four (4) out of twelve (12) declined to be interviewed During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Apolinario ‘Paul’ Gozon, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 11-AS-20251217104629

Allegation investigated: Staff did not allow residents to select their hospice provider

On 2/4/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Paul Gozon and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 2/4/26, LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Hospice Provider Pamphlets, List of Referrals and List of Residents using Hospice Services. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-5 (S1 – S5), and Witness 1 – Witness 4 (W1-W4). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not allow residents to select their hospice provider It is being reported that the facility is restricting the ability of residents and families to choose their own hospice care. On 2/4/26, LPA Felisa Shirley requested the list of residents currently using hospice providers. LPA Shirley received a list of 8 residents, 2 residing in Assisted Living and 6 residing in Memory Care. During the investigation, LPA Shirley requested information regarding the hospice services the company uses. LPA Shirley received information packets from 11 different hospice providers. LPA Shirley observed that residents are utilizing varied hospice care providers. Per interview with S-2 on 2/4/26, Clearwater provides families with resources to make informed decisions about hospice care options. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed witness 1 – witness 4 (W1 – W4). Of those who interviewed 4 out of 4 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not allow residents to select their hospice provider,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Paul Gozon.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 11-AS-20260130134136

Type of visit: Annual/Random

On 12/23/2025 at 8:31, Licensing Program Analysts (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Executive Director, Apolinario ‘Paul’ Gozon, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. The facility has been approved for delayed egress in the memory care and transitional units. Physical Plant/Structure The facility is located in a commercial area. It consists of two buildings, one building is designated for Assisted Living and Memory Care residents and has two (2) floors. The additional building is for Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business offices, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room, and five (5) outside shaded patio areas with tables and chairs. LPA did not observe any bodies of water on the premises. LPA observed all walkways and passages outside the facility to be clean, clear, and free of obstructions, debris, and hazards. Resident Rooms During the facility tour, LPA inspected ten (10) resident apartments and observed them to be clean and in good repair. The resident rooms inspected were rooms 105, 109, 206, 307, 310, 113, 120, 205, and 225. Resident’s apartments are furnished with their personal furniture. LPA observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPA observed beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the residents, but the facility does have a storage room with linens, and blankets in case a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPA observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPA observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for residents’ use. LPA observed the multipurpose/activity room to have tables and ample chairs. LPA observed an ample supply of arts and craft supplies available for resident use. The activity schedule was posted outside the door. The dining room had multiple tables and chairs to accommodate residents. LPA observed snacks and drinks are available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms, walkways and hallways in the facility were observed with ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. Kitchen LPA inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPA observed all appliances to be in good working repair. LPA observed an ample supply of cookware, dishware, and cutlery in good repair. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPA reviewed the temperature logs for the freezer and the refrigerator. LPA observed the monthly menus posted in the dining room and at the entrance of the dining room. LPAs observed all cleaning supplies secured in a locked storage room and are inaccessible to residents. Safety LPA observed multiple fully charged fire extinguishers last serviced on 10/20/25. The last annual fire inspection was conducted on 09/19/25. LPA observed smoke detectors and carbon monoxide detectors to be operational. LPA received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E) last updated on 01/16/2025. The last Emergency Drill was conducted on 10/16/25. The facility does have a working landline telephone. LPA observed all required posting throughout the facility. LPA reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators. Medications LPA observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original containers. LPA reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten (10) out of ten (10) residents’ MARs and medications are consistent with properly documented records. Files LPA reviewed ten (10) resident files and found they contained the required documents. LPA reviewed the Administrator and six (6) staff files and found they contained the required documents, clearance, certification, and training. LPA received and reviewed a copy of the Liability insurance through Acord valid till 11/11/2026. During file review, LPA observed the Licensing Fees are current. Infection Control LPAs observed multiple hand sanitizing stations throughout the facility. LPAs observed an ample supply of hand soap and paper towels. LPAs observed required infection control signs posted throughout the facility. LPAs observed a 60-day supply of Personal Protective Equipment (PPE). During today's visit, LPAs did not observe or cite any deficiencies. An exit interview was conducted with Business Office Manager, Raul Periera and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

Allegation investigated: Staff did not properly follow reporting requirements

On 10/23/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced initial complaint visit at the facility. LPA was met by staff one, Paul Gozon - Executive Director (S1) and the purpose of the visit was explained. The investigation consisted of the following: LPA requested and reviewed the following documents: Resident and staff roster (dated: 10/23/25), special incident reports of residents in care (dated: 09/01/25 through 10/01/25), hospice care notes (dated: 09/01/25 through 10/01/25) and pre-admission and admission appraisals as well as facility vitals. LPA interviewed seven (7) staff (S1-S7) and three (3) residents (R1-R3). Report continues, please see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation, "Staff has inadequate record keeping", it is being alleged that the facility does not include important information regarding an incident that has occurred to a resident in care. Interviews revealed the following: four (4) out of seven (7) staff have confirmed that a resident was observed, after a fall, on the right hand side of their body, while three (3) staff were not familiar how the resident was observed after this fall. Hospice notes were observed, which indicated that there were no abnormal vitals recorded on 09/16/25, 09/17/25 and 09/26/25. Notes from staff at the facility have been recorded during the time period of 04/11/25 through 10/04/25, no abnormalities of documentation has been observed. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. The investigation revealed the following: Regarding the allegation, "Staff did not properly follow reporting requirements", it is being alleged that the facility has not submitted a special incident report (LIC624) within California's required timeline. Upon receiving the LIC624, lpa reviewed the dates recorded on the LIC624. Per title 22 regulation, a facility is to submit a written report within seven (7) days after the occurrence of an injury to any resident(s) in care. The injury took place on 09/15/25, leaving until 09/22/25 for the facility to submit LIC624; whereas the report was not submitted to CCL until 09/34/25. Interviews revealed that four (4) out of seven (7) staff were not accurate of the requirements to report incidents to Community Care Licensing (CCL) division following an injury. Furthermore, S1 confirmed that the facility has not reported this incident to CCL in a timely manner. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. One deficiency has been cited during today's visit. An exit interview was held with staff one, Paul Gozon - Executive Director (S1) and a copy of this report, citation(s) cited and facilities' appeal rights have been provided to S1.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 11-AS-20251014124606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 29, 2025

87211 Reporting Requirements (a) Each licensee shall furnish...as the Department may require, including, but not limited to, the following: (1) A written report...for the resident within seven days any..specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This has not been met as evidenced by a delay in reporting which indicates the licensee has failed to followthe state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: LPA and S1 have confirmed that the facility will conduct an in-staff training for all supervisors and med-tech staff who reside at this facility. S1 will forward this documentation to LPA, by email, at MARIO.LEON@DSS.CA.GOV on or prior to POC due date, 10/29/25.

Allegation investigated: Staff did not ensure air conditioner was working properly

On 09/04/2025, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Paul Gozon, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Work Orders, and invoices for C&M Mechanical dated 05/29/2025, 07/09/2025, 07/25/2025, 08/12/2025, 08/15/2025, and 08/29/2025. The investigation revealed the following: Unsubstantiated Allegation: Staff did not ensure air conditioner was working properly The allegation alleges the facility is not kept at a comfortable temperature and the air condition is not working properly. During record review, LPA received and reviewed invoices from C&M Mechanical dated 05/29/2025, 07/09/2025, 07/25/2025, 08/12/2025, 08/15/2025, and 08/29/2025. During the visit conducted on 08/29/2025 the technician inspected all rooms with temperature complaints to verify the status of fan coils. The technician found no error codes on the AC units specified rooms. The technician observed that the fan coils in all rooms with temperature complaints were turned off at the thermostats. Additionally, the technician observed some of the rooms had open windows and blinds, contributing to the heat issue. During the visit on 08/12/2025, the technician observed the fan coil seemed closed due to pipe temperature not changing in rooms 207, 203, and 201. Room 101 had closed ports. The technician observed a loose not on ball valve. The technician tightened the nut and made sure the ball valves were opened. On 08/05/2025, 08/08/2025, and 08/12/2025 filters were changed, and the condenser coils were checked and cleaned. On 07/25/2025, the technician checked room 204 whose thermostat was set to off, when turned on, the thermostat setting was on heating. It was switched to cooling, then functioned properly. The technician checked Room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 07/09/2025, the technician checked room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 05/29/2025, room 107 had an error code. The technician changed the main PCB board, and the error cleared. In room 112 the motors were going bad. The technician changed the motor and the main PCB board for fan coil. On 05/06/2025, the technician checked the main units on the roofs. The technician observed one unit was not getting power due to the breaker not fully in the on position. The technician conducted a diagnostic and did not find any additional issues. During the facility tour, LPA took the temperature of all common areas and eleven resident rooms. The following temperatures were recorded in the assisted living lobby the temperature measured 74.3-degrees, the dining room measured 73.6-degrees, the activity room measured 72.1-degrees, the first-floor hallways measured 75.3, 73.2, and 74.3-degrees, and the second-floor game room measured 75.6-degrees Fahrenheit. The following rooms temperature was measured in the assisted living, room 103 measured 75.5-degrees, room 108 measured 76.4, room 209 measured 77-degrees, room 215 measured 76.6-degrees, 235 measured 77.3-degrees, and room 242 measured 70.7-degrees Fahrenheit. The following temperatures were measured in the Memory Care Unit, the hallway measured 75.2-degrees, the dining room measured 73.0-degrees, and the activity area measured 76.1-degrees. The following rooms temperature was measured in the memory care unit, room 117 measured 76.6-degrees, and room 118 measured 73.7-degrees Fahrenheit. The following temperatures were measured in the Clearbrook building first-floor common area measured 73.2-degrees, the second-floor common area measured 74.3-degrees, and the third floor measured 71.6-degrees Fahrenheit. LPA observed all resident rooms have a thermostat to control the temperature in their room. LPA observed thermostats accessible in common rooms. During interviews with Staff S1-S8, were asked if there have been any issues with the air conditioning in the building, two (2) out of eight (8) stated there was an issue with one of the units that has been repaired. Additionally, during interviews with Staff S1-S3, were asked if the HVAC system is maintenance, three (3) out of three (3) stated it is maintenance quarterly. During interviews with residents R1-R10, were asked if the air conditioning is functioning properly in their room, eight (8) out of ten (10) stated there are no issues with their air conditioning. Additionally, residents R1-R10 were asked if the facility is maintained at a comfortable temperature, ten (10) out of ten (10) stated the facility is kept at a comfortable temperature. Three (3) residents stated the activity room can get too cold. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 11-AS-20250826092317

Allegation investigated: Staff are not ensuring all staff are criminally record cleared

On July 10, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted unannounced initial complaint visit regarding above allegation. LPA Lee met with Raul Gosan, Executive Director, and Raul Pereirra, Business Office Director, and explained the reason for the visit. Investigation consisted of the following: On 7/10/25, LPA obtained copies of the LIC 500 (dated 6/23/25) LPA reviewed 10 staff files (S2-S11), LPA conducted 2 staff interviews with Executive Director (A1) and Business of Director (S1). LPA and Business Office Director toured the facility. Page 1 of 2 Unsubstantiated The investigation revealed the following: Allegation: Staff are not ensuring all staff are criminally record cleared The complaint alleges that “applicants are being hired and are being scheduled on the floor before having and passing a live scan and physical/medical testing.” On 07/10/25, at 9:30am, LPA Lee interviewed the Executive Director (A1) who denied the allegation stating that all applicants are criminally and medically cleared before they are able to work on the floor. On 7/10/25 at 10:30am LPA interviewed the Business Office Director (S1) who denied the allegation stating that he personally makes sure all applicants are criminally and medically cleared before hire. On 7/10/25, LPA reviewed the staff roster/schedule (6/23/25), and cross checked with the Department’s Personnel Report Summary (LIS) and did not observe any discrepancies On 7/10/25, LPA reviewed 10 staff files (S2-S11) and of those reviewed, 10 out of 10 had all required criminal clearance and medical clearance documents including TB/chest X-rays. Each staff file reviewed was in compliance with Title 22 regulations and had the required documentation. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that Staff are not ensuring all staff are criminally record cleared. 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 interviewed conduct and report provided to Executive Director, Paul Gozon. No deficiencies cited during today's visit. Page 2 of 2the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250703110413

Type of visit: Case Management - Other

On 06/26/2025 at 9:46 PM, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to deliver an Immediate Exclusion of a staff. LPA met with Executive Director, Paul Gozon, and the purpose of today's visit was explained. LPA was granted entry into the into the facility. During today's visit LPA delivered an Immediate Exclusion Letter for Daniel Castro due to conduct inimical. Daniel Castro is not to have contact with clients and cannot be physically at the facility. Daniel Castro was not present at the facility during time of visit. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 26, 2025

Allegation investigated: Staff have not provided authorized representative a copy of resident's file

This report serves as an amendment to change a finding. This report supersedes the complaint investigation findings reflected on report created 01/30/25. On 04/30/2025, Licensing Program Analyst (LPA), conducted an unannounced subsequent complaint visit to the facility listed above to deliver findings. LPA met with Office Business Director, Raul Pereira, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During a visit on 01/30/25, LPA toured the facility and received additional documents. The documents received and reviewed are staffing notes for R1. During a subsequent visit conducted on 10/24/23, LPA inspected the facility, interviewed Staff S1-S12, interviewed Residents R3-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, staff Training Logs regarding ADL’s, Toileting/Incontinence, emails between S1, S2 and residents’ family, Resident’s Face Sheet, Physician’s Report, Consent Forms, Resident South Bay Health and Service Evaluation Service Plan, Power of Attorney, Centrally Stored Medications, Resident Intake Form, Admission Agreement, Outside Agency Documents, and Hospital Discharge Documents. Substantiated The investigation revealed the following: Allegation: Staff have not provided authorized representative a copy of residents’ file. The complaint allegation alleges that a resident’s authorized representative has requested a copy of the residents’ rental agreement and visitor logs and have not received them. During a record review the Department received and reviewed Residents R1 and R2 Heath Information Release Authorization, dated 03/22/2023, that states Resident’s son or daughter are authorized to receive all medical records. Additionally, the department received and reviewed R1 and R2’s California Uniform Statutory Power of Attorney dated 10/23/2017, that allows the son and daughter to act as agents with the powers in California Probate Code Sections 4400-4465. The department received and reviewed a Durable Power of Attorney dated 07/23/2024 for R1 and R2 naming their daughter and son as appointed Power-in-Fact. Additionally, LPA received and reviewed emails between Residents R1 and R2’s authorized representative and facility Staff S2, dated 08/19/2024, when the initial request for “all of their records” were made. On 08/28/2024, an email was sent to S2 following up on the status of the resident records requested. On 09/13/2024, an additional email was sent to S2 following up on the status of the resident records requested. During interviews with Staff S1-S12, were asked if a resident’s representative requested documents regarding their resident how long does it take to process their request, four (4) out of twelve (12) stated it could take 24-hours to a week to processes that request. Additionally, Eight (8) out of twelve (12) stated they are not sure how long it would take, and they would instruct the residents authorized representative to speak to S2 regarding the request. Additionally, S1 stated they sent all the documents that were requested. During interviews with Residents R3-R11, were asked if them or their family has requested documents from the facility and if they received the documents requested, five (5) out of nine (9) stated their family got documents right away. Additionally, four (4) out of nine (9) stated they have not requested any documents from the facility. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Business Office Manager, Raul Pereira, and a copy of this report and the Appeal Rights were provided. Allegation: Due to staff neglect, resident sustained a wound. The complaint allegation alleges that a resident was observed with an abscess from an unknown cause. During record review the department received and reviewed discharge paperwork from Torrance Memorial Hospital dated 08/15/2024. On 08/12/2024 R1 was admitted to Torrance Memorial Hospital and discharged on 08/15/2024, on the discharge paperwork the department did not observe any indication of an abscess. R1 returned to the facility with a private caregiver till they were transferred to a skilled nursing facility. On 08/18/2024, R1 was admitted to Berkley Post-Acute for physical therapy and occupational therapy. On 08/23/2024, R1 was prescribed Bactrim DS Tablet 800-160 MG for abscess on pubical area. The Transfer/Discharge Report from Berkley Post-Acute dated 08/26/2024 on diagnoses listed is “other specified dermatitis.” The discharge summary from Berkley Convalescent Hospital dated 08/26/2024 indicates R1 has a wound on the groin area. The facility provided a document for Outside Agency Documentation dated on 09/03/2024, AllCare Home Health conducted a visit for Wound Care on the groin. The department received and reviewed a prescription order, dated 08/28/2024, for Mupirocin, an ointment to be applied to an abscess for the groin. The department received and reviewed the electronic Medication Administration Record (eMAR) for R1 for the months on August and September 2024 that indicates the cream was applied three (3) times a day as prescribed. During interviews with Staff S1-S12, were asked if any residents have sustained a wound due to neglect such as being left in soiled diaper for an extended period of time, or lack of hygiene care, twelve (12) out of twelve (12) stated no, they have no knowledge of a resident sustaining wounds due to neglect. During interviews with Resident’s R3-R11, were asked if they have sustained a wound due to neglect, nine (9) out of nine (9) stated they have not sustained injuries due to neglect. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are double diapering residents. The complaint allegation alleges that resident was placed in double diapers overnight. During record review the department received and reviewed In-Service Training Log and material used in the training conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy stated, “incontinence products should be used, if appropriate, and the resident’s incontinence product should be changed as needed.” During interviews with Staff S1-S12, were asked if residents are placed in double diapers, twelve (12) out of twelve (12) stated no residents are placed in double diapers. Additionally, staff S1-S12 were asked if they have heard of a residents placed in double diapers, eleven (11) out of twelve (12) stated they have not heard that from a resident or a resident’s family. S2 stated R2’s daughter informed them that R2 was observed with double diapers on two (2) occasions. S2 stated it was addressed right away with the staff and an In-Service Training was conducted to ensure it did not happen again. During interviews with Resident’s R3-R11, were asked if they have been placed in double diapers, nine (9) out of nine (9) stated they have not been placed in double diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff left resident in soiled diapers. The complaint allegation alleges that resident is left in soiled diapers. During file review at the facility, the department received and reviewed a copy of the Care Partner Job Description that states care partners need to frequently check to see if incontinent residents need changed. Additionally, the department received and reviewed In-Service Training Log and material used conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy states staff will “Initiate toileting at least every two (2) hours and prior to typical “pattern” time. During an interview with the Administrator S1, was asked how often residents are assisted with incontinence, S1 stated residents are assisted every two (2) hours and some residents do require additional checks due to increased urine output from medications or fluid intake. During interviews with Staff S2-S12, were asked how often incontinent residents are assisted with changing, eleven (11) out of eleven (11) stated residents are assisted with changing every 2 hours if not more. During interviews with Residents R3-R11, were asked if they have been left in soiled diapers for an extended period of time, nine (9) out of nine (9) stated they have not been left in soiled diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit the department did not observe or cite any deficiencies. An exit interview was conducted with Business Office Manager, Raul Pereira, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 11-AS-20241016160832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: May 10, 2025

87468.2Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed... the elderly shall have all of the following persoanl rights (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This regulation was not met based on record review, Resident R1 and R2's representative was not provided copies of Resident's file within two (2) business days.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Administrator will reviewed Title 22 regulations section 87468.2 and email LPA that the section was reviewed and understood by POC due date. LPA email: wendy.gibbs@dss.ca.gov

Allegation investigated: Staff have not provided authorized representative a copy of resident's file Due to staff neglect, resident sustained a wound Staff are double diapering resident Staff left resident in soiled diapers

On 01/30/2025, the department conducted a subsequent visit to the facility listed above to deliver findings for a complaint. The department met with Executive Director, Paul Gozon, and the purpose of the visit was explained. During today’s visit, the department toured the facility and received additional documents. The documents received and reviewed are staffing notes for R1. During a subsequent visit conducted on 10/24/23, the Department inspected the facility, interviewed Staff S1-S12, interviewed Residents R3-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, staff Training Logs regarding ADL’s, Toileting/Incontinence, emails between S1, S2 and residents’ family, Resident’s Face Sheet, Physician’s Report, Consent Forms, Resident South Bay Health and Service Evaluation Service Plan, Power of Attorney, Centrally Stored Medications, Resident Intake Form, Admission Agreement, Outside Agency Documents, and Hospital Discharge Documents. The investigation revealed the following: Unsubstantiated Allegation: Staff have not provided authorized representative a copy of residents’ file. The complaint allegation alleges that a resident’s authorized representative has requested a copy of the residents’ rental agreement and visitor logs and have not received them. During a record review the Department received and reviewed Residents R1 and R2 Heath Information Release Authorization, dated 03/22/2023, that states Resident’s son or daughter are authorized to receive all medical records. Additionally, the department received and reviewed R1 and R2’s California Uniform Statutory Power of Attorney dated 10/23/2017, that allows the son and daughter to act as agents with the powers in California Probate Code Sections 4400-4465. The department received and reviewed a Durable Power of Attorney dated 07/23/2024 for R1 and R2 naming their daughter and son as appointed Power-in-Fact. Both documents give the daughter and son the authority to make decisions for their parents regarding finances and property. During interviews with Staff S1-S12, were asked if a resident’s representative requested documents regarding their resident how long does it take to process their request, four (4) out of twelve (12) stated it could take 24-hours to a week to processes that request. Additionally, Eight (8) out of twelve (12) stated they are not sure how long it would take, and they would instruct the residents authorized representative to speak to S2 regarding the request. Additionally, S1 stated they sent all the documents to the daughter that were requested. During interviews with Residents R3-R11, were asked if their family has requested documents from the facility and if they received the documents requested, five (5) out of nine (9) stated their family got documents right away. Additionally, four (4) out of nine (9) stated they have not requested any documents from the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Due to staff neglect, resident sustained a wound. The complaint allegation alleges that a resident was observed with an abscess from an unknown cause. During record review the department received and reviewed discharge paperwork from Torrance Memorial Hospital dated 08/15/2024. On 08/12/2024 R1 was admitted to Torrance Memorial Hospital and discharged on 08/15/2024, on the discharge paperwork the department did not observe any indication of an abscess. R1 returned to the facility with a private caregiver till they were transferred to a skilled nursing facility. On 08/18/2024, R1 was admitted to Berkley Post-Acute for physical therapy and occupational therapy. On 08/23/2024, R1 was prescribed Bactrim DS Tablet 800-160 MG for abscess on pubical area. The Transfer/Discharge Report from Berkley Post-Acute dated 08/26/2024 on diagnoses listed is “other specified dermatitis.” The discharge summary from Berkley Convalescent Hospital dated 08/26/2024 indicates R1 has a wound on the groin area. The facility provided a document for Outside Agency Documentation dated on 09/03/2024, AllCare Home Health conducted a visit for Wound Care on the groin. The department received and reviewed a prescription order, dated 08/28/2024, for Mupirocin, an ointment to be applied to an abscess for the groin. The department received and reviewed the electronic Medication Administration Record (eMAR) for R1 for the months on August and September 2024 that indicates the cream was applied three (3) times a day as prescribed. During interviews with Staff S1-S12, were asked if any residents have sustained a wound due to neglect such as being left in soiled diaper for an extended period of time, or lack of hygiene care, twelve (12) out of twelve (12) stated no, they have no knowledge of a resident sustaining wounds due to neglect. During interviews with Resident’s R3-R11, were asked if they have sustained a wound due to neglect, nine (9) out of nine (9) stated they have not sustained injuries due to neglect. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are double diapering diapers. The complaint allegation alleges that resident was placed in double diapers overnight. During record review the department received and reviewed In-Service Training Log and material used in the training conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy stated, “incontinence products should be used, if appropriate, and the resident’s incontinence product should be changed as needed.” During interviews with Staff S1-S12, were asked if residents are placed in double diapers, twelve (12) out of twelve (12) stated no residents are placed in double diapers. Additionally, staff S1-S12 were asked if they have heard of a residents placed in double diapers, eleven (11) out of twelve (12) stated they have not heard that from a resident or a resident’s family. S2 stated R2’s daughter informed them that R2 was observed with double diapers on two (2) occasions. S2 stated it was addressed right away with the staff and an In-Service Training was conducted to ensure it did not happen again. During interviews with Resident’s R3-R11, were asked if they have been placed in double diapers, nine (9) out of nine (9) stated they have not been placed in double diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff left resident in soiled diapers. The complaint allegation alleges that resident is left in soiled diapers. During file review at the facility, the department received and reviewed a copy of the Care Partner Job Description that states care partners need to frequently check to see if incontinent residents need changed. Additionally, the department received and reviewed In-Service Training Log and material used conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy states staff will “Initiate toileting at least every two (2) hours and prior to typical “pattern” time. During an interview with the Administrator S1, was asked how often residents are assisted with incontinence, S1 stated residents are assisted every two (2) hours and some residents do require additional checks due to increased urine output from medications or fluid intake. During interviews with Staff S2-S12, were asked how often incontinent residents are assisted with changing, eleven (11) out of eleven (11) stated residents are assisted with changing every 2 hours if not more. During interviews with Residents R3-R11, were asked if they have been left in soiled diapers for an extended period of time, nine (9) out of nine (9) stated they have not been left in soiled diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit the department did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 11-AS-20241016160832

Allegation investigated: Staff did not safeguard resident's personal items Staff did not document or report incidents to resident's authorized person Staff did not provide activities for residents Staff mismanage resident medication Staff do not safeguard confidential information Staff do not provide utensils for residents Staff are unable to communicate with residents

On 09/06/24, Licensing Program Analyst, Wendy Gibbs, conducted a subsequent visit to the facility listed above to deliver findings. LPA met with Assistant Executive Director/Memory Care Director, Cecille Bernabe, and Office Business Director, Raul Periera, and the purpose of today’s visit was explained the purpose of today’s visit. During a subsequent visit conducted on 12/20/23 LPA interviewed staff (S1-S9) and residents (R2-R3), toured the facility, and received pertinent documents for the investigation. LPA reviewed and received copies of the following documents, staff roster, resident roster, resident Appraisal, Needs and Service Plans, Physician’s Report, Nurse/Staff Notes, Safeguard of property/valuables, incident reports, Centrally Stored Medications, Medication Administration Record (MAR), Weight Log, Activity Schedule, Menu, Laundry Schedule, Cleaning Schedule, and staff Training Logs. On an additional subsequent visit conducted on 02/09/24, Licensing Program Analysts (LPA), Wendy Gibbs and Alfonso Iniguez met with Executive Director, Paul Gozon. During the visit LPAs toured the (1A) Continued on LIC9099-C Unsubstantiated facility, interviewed Residents (R1-R6), interviewed Staff (S6-S9), and received documents pertinent to the investigation. The documents reviewed and received include Staff Roster, Resident Roster for Memory Care Unit, Staff Training Logs of 100 modules Dementia Care and 10 modules on Falls, Resident Admission Agreement, Physician Reports, Communication Logs, and Safeguard of Property. During an additional subsequent visit conducted on 08/29/24, LPA met with Assistant Executive Director/Memory Care Director, Cecille Bernabe and Office Business Manager, Raul Pereira. During the visit, LPA toured the facility, interviewed Staff S2, and received documents pertinent to the investigation. The documents received and reviewed include Unusual Incident/ Injury Reports (SIR)s, Outside Agency Documentation, Skin Integrity Monitoring Form, Internal Occurrence report, and resident Hospital Discharge paperwork. The investigation revealed the following: Allegation: Staff did not safeguard resident’s personal items The complaint allegation alleges resident’s personal items such as clothes and tooth brush have gone missing. During the facility record review, LPA received and reviewed a copy of the Client/Resident Personal Property and Valuables (LIC621) for sis residents. LPA observed six (6) out of six (6) residents declined to fill out the form. During review of residents Admission Agreement, LPA observed in Appendix K Safeguard of Resident Property on page 2 states “the facility shall not be liable for items which have not been requested to be included in the inventory or for items which have (2A) Continued on LIC9099-C been deleted from the inventory.” During interviews with Staff S1-S8, were asked how the facility safeguards residents personal belongings, eight (8) out of eight (8) stated they encourage residents to keep personal belongings in their room and to lock their door when they leave their rooms. During interviews with Residents R1-R6, were asked if they had any items go missing, six (6) out of six (6) stated they have had no items go missing. Allegation: Staff did not document or report incidents to resident’s authorized person The complaint allegation alleges the responsible person was not notified of residents falls or injuries. During record review of Resident R1’s Progress Notes, LPA observed staff called the responsible party to inform them of incident’s that occurred on the following dates: 08/21/23, 09/20/23, 11/10/23, 12/14/23, 12/22/23, 12/29/23, and twice on 12/30/23. LPA observed messages were left on 12/29/23 and 12/30/23 until they were able to get in contact with the responsible party. LPA observed in the notes when they called a number for the responsible party, they kept getting a message stating the phone was waiting to connect, and the phone is unavailable. Additionally, LPA observed in the notes the staff left a message on an alternative phone number listed. In which, staff was informed by the responsible party that they were no longer using the number where they messages were left. During interviews with Staff S1-S8, were asked if residents responsible party is (3A) Continued on LIC9099-C notified if a resident has a fall or sustains an injury, eight (8) out of eight (8) stated the responsible party is notified of a residents fall, injury, or change of condition as soon as possible. During interviews with Resident R1-R6, were asked if their responsible party is notified of any fall, injuries, or change of condition, six (6) out of six (6) stated their family is notified of falls and injuries. Allegation: Staff did not provide activities for residents The complaint allegation alleges staff do not provide activities for the residents. During records review, LPA Iniguez observed copies facility activities calendar from October, November, and December 2023. During a tour of the facility, LPA Gibbs and Iniguez observed activities being performed to the residents in care. In addition, posting of daily activities is available in the common areas accessible to residents in care. During an interview with administrator (S#1) he stated that the facility offers activities for residents in care. During interviews with residents (R#1-R#6) (6) out of (6) stated that the facility provides activities. During an interview with facility staff (S#2-S#9) eight (8) out of eight (8) stated that the facility offers activities for residents in care, if they would like to participate. Allegation: Staff mismanaged resident medication The complaint allegation alleges that the Med Tech was unavailable when the family of a resident requested a PRN medication. During records review, LPA Iniguez observed copies of memory care Med Tech medication training logs. In addition, LPA Iniguez observed staff received training (4A) Continued on LIC9099-C concerning emergency events in their Relias modules. During a tour of the facility, LPAs Gibbs and Iniguez observed Med Techs in the Towers main medication room on the first floor. LPAs reviewed six (6) residents’ medication and electronic Medication Administration Record (eMar) and observed six (6) out of six (6) residents eMAR’s and medication are consistent with properly documented records. During an interview with administrator (S#1) he stated that the facility staff is trained regarding first aid assistance. During interviews with residents (R#1-R#6) six (6) out of six (6) stated they receive their medication when prescribed and PRNs when needed. During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated residents are given their medications as prescribed and follow procedure for PRN medications. Allegation: Staff do not safeguard confidential information The complaint allegation alleges that resident’s information and confidential information is not kept in a safe place. During the facility tour, LPAs Gibbs and Iniguez observed resident’s medical files secured in the locked medication room. Additionally, during the tour, LPAs observed residents’ facility documents secured in the locked business office managers office. During interviews with Staff S1-S8, were asked how they keep residents personal information safeguarded, eight (8) out of eight (8) stated personal files for the resident are locked in the medication room and the office. Additionally, eight (8) out of eight (8) stated they do not provide any information to any person other than the (5A) Continued on LIC9099-C residents responsible party, physician, home health, or hospice representative. During interviews with Residents R1-R6, were asked if the facility safeguards their personal information, six (6) out of six (6) stated the facility safeguards their information. Allegation: Staff do not provide utensils for residents The complaint allegation alleges that residents are given their meals without utensils and residents eat their food with their hands. When LPA’s Iniguez and Gibbs arrived at the facility the residents were having breakfast and LPAs observed residents were provided with utensils. Additionally, LPA’s observed lunch being served to residents in the Tower and utensils were provided. During the facility tour, LPAs observed an ample supply of utensils in the kitchen. During interviews with Staff S1-S8, were asked if residents are provided with utensils during meals and snack, eight (8) out of eight (8) stated residents are provided with utensils. During interviews with Residents R1-R6, were asked if they are provided with utensils during meals, six (6) out of six (6) stated yes, they are provided with utensils for meals. Allegation: Staff are unable to communicate with residents The complaint allegation alleges that staff are unable to communicate with residents. During records review, LPA Iniguez observed that facility staff have taken the following courses in Relias: Communication and People with Dementia, Cultural (6A) Continued on LIC9099-C competence, Ethical Considerations and The Aging Process. These courses emphasize the importance of communication. During an interview with administrator (S#1) he stated that the facility staff is able to communicate with the residents. Also, (S#1) stated that the facility staff does not have problems understanding the residents in care. During interviews with residents (R#1-R#6) (5) out of (6) stated that they are able to communicate with the facility staff and they do not have problems understanding what the facility staff says to them. During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated that they are able to communicate with the residents in care and some of the ways they used are: reviewing resident’s records, taking their time to make sure residents understand them. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Assistant Executive Director/Memory Care Director, Cecille Bernabe, and Office Business Director, Raul Periera, and a copy of this report was provided. (7A)the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 11-AS-20231214094359

The state marks this report as 16 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 08/02/24, Licensing Program Analysts (LPA), Wendy Gibbs, Deborah Lee, and Yolanda Rosser, conducted an unannounced visit to the facility listed above. LPA’s met with Assistant Executive Director, Cecille Bernabe, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. Delayed egress approved for memory care and transitional units. Physical Plant/Structure The facility consists of two buildings, one building is designated for Assisted Living and Memory Care residents and consists of two (2) floors and the other building consists of Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units’ rooms, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business office, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room and four (4) outside shaded patio with table and sufficient chairs and putting green. LPAs did not observe any bodies of water on the premises. LPAs observed all walkways and passages around the facility to be clean, clear, and free of obstructions, debris, and hazards. Resident Rooms During the facility tour, LPAs inspected twelve (12) resident apartments and observed them to be clean and in good repair. The resident apartments inspected were 102, 106, 206, 219, 214, 216, 224, 232, 117, 104(M), 210(M), and 308(M). Resident’s apartments are furnished with their personal furniture. LPAs observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPAs observed beds to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the resident, but the facility does have a storage room with linens, and blankets incase a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPAs observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPAs observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for resident use. LPAs observed the multipurpose/activity room to have tables and ample chairs. LPAs observed an ample supply of arts and craft supplies available for resident use. The activity schedule was posted outside the door. The dining room had multiple tables and chairs to accommodate residents. LPA’s observed snacks, and drinks available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms and hallways were observed with ample lighting. LPAs observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. Kitchen LPAs inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPAs observed all appliance to be in good working repair. LPAs observed an ample supply of cookware, dishware, and cutleries in good repair. LPAs observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPAs reviewed the temperature logs for the freezer and the refrigerator. LPAs observed the monthly menus posted in the dining room and at the entrance of the dining room. LPAs observed all cleaning supplies secured in a locked storage room and are inaccessible to residents. Safety LPAs observed multiple fully charged fire extinguishers last serviced on 09/12/23. The last annual fire inspection was conducted on 10/10/23. LPAs observed smoke detectors and carbon monoxide detectors to be operational. LPAs received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E). The last Emergency Drill was conducted on 06/16/24. The facility does have a working landline telephone. LPAs observed all required posting throughout the facility. LPAs reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators. Medications LPAs observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original container. LPAs reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten out of ten resident’s MARs and medications are consistent with properly documented records. Files LPAs reviewed 12 resident files and found they contained the required documents. LPAs reviewed the Administrator and eight (8) staff files and found they contain the required documents, certification, and training. LPAs received and reviewed a copy of the facility’s Liability Insurance. During file review, LPAs observed the licensing fees are current. Infection Control LPAs observed multiple hand sanitizing stations throughout the facility. LPAs observed an ample supply of hand soap and paper towels. LPAs observed required infection control signs posted throughout the facility. LPAs observed a 60-day supply of Personal Protective Equipment (PPE). During today's visit, LPAs did not observe or cite any deficiencies. An exit interview was conducted with Business Office Manager, Raul Periera, and Assistant Executive Director, Cecile Bernabe, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 2, 2024

Allegation investigated: Facility HVAC is in disrepair.

On 07/17/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced complaint visit to the facility listed above. LPA met with Assistant Executive Director, Cecille Bernabe, and Business Office Director, Raul Pereira, and the purpose of today’s visit was explained. During today’s visit LPA toured the facility, took room temperatures, interviewed Staff S1-S8, interviewed residents R1-R10, and received documents pertinent to the investigation. LPA received and reviewed the following documents, Staff Roster, Resident Roster, Work Orders, and invoices from AC company. The investigation revealed the following: Continued On LIC9099-C Unsubstantiated Allegation: The facility HVAC is in disrepair The allegation alleges that the facility has had a broken air conditioning and heating system for about two (2) years. During the facility tour, LPA used a thermometer to measure the temperature in common rooms and resident rooms. In common rooms, in both buildings, LPA observed the thermostats were set between 72-degrees and 78-degrees Fahrenheit, and the temperatures measured 74.3-degrees in the game room, 74.8-degrees in the facility entry, 73.2-degrees in the activity room, 76.7-degrees in the dining room, 77.3-degrees in the lounge area, 75.3-degree in the 1st floor activity room, 70.6-degrees in the 2nd floor multipurpose room, and 74.0-degrees in the 3rd floor multipurpose room. In the resident rooms inspected, LPA observed each room had their own thermostat for residents to control the temperature in their rooms and to set it at the temperature of their choice. The following rooms were inspected, temperatures recorded, and thermostats checked, room 104 measured 74.4-degrees and thermostat set at 74-degrees, room 107 measured 71.9-degrees and thermostat set at 72-degrees, room 112 measured 74.3-degrees and thermostat set at 75-degrees, room 117 measured 71.4-degrees and thermostat set at 72-degrees, room 124 measured 76.6-degrees and thermostat set at 76-degrees, room 203 measured 77.5- degrees and thermostat set at 78-degrees, room 205 measured 75.3 and thermostat set at 74-degrees, room 212 measured 72.2-degrees and thermostat set at 72-degrees, room 221 measured 77-degrees and the thermostat set at 76-degrees, room 224 measured 74.3-degrees and Continued on LIC-9099-C thermostat set at 74-degrees, room 229 measured 74.3-degrees and thermostat set at 73-degrees, and room 235 measured 78.6 and thermostat set at 77-degrees. During record review, LPA received and reviewed an invoice from Providence Consulting & Design, LLC for air conditioning maintenance, dated on 05/13/24. Additionally, LPA received and reviewed the facility’s Work Orders from 05/01/24 to present and observed there were twenty-one (21) work orders regarding the air conditioning, and 10 of the work orders were a request to adjust the thermostat for the room being either hot or cold. During an interview with S3 and S4 stated that some of the residents do not know how to adjust the thermostat and have complained in the past about it either being too hot or too cold or the thermostat not working. During interviews with Staff S1-S8, were asked if the air conditioning works in both buildings, eight (8) out of eight (8) stated the air conditioning works in all rooms. During interviews with S3 and S4, stated maintenance was conducted on the HVAC system on 05/13/24, and some of the rooms AC did not work during the maintenance but residents were provided with a portable air conditioner and fans. Additionally, S3 and S4 stated the main air conditioning units were replaced almost 2 years ago. During interviews with Staff S6-S8, stated the HVAC system is serviced twice a year, right before summer and right before winter. LPA asked Staff S2-S8 if they have received any complaints regarding the air conditioning, seven (7) out of seven (7), stated there have been complaints of resident rooms either being too hot or too cold and when the room is checked there are many instances that the resident has had difficulties operating the thermostat. Continued on LIC9099-C During interviews with Residents R1-R10, were asked if there have been any issues with their air conditioning in their rooms, eight (8) out of ten (10) stated there have been no issues with their air conditioning. Resident R1 stated their thermostat is broken and doesn’t work. LPA went to the resident’s room and tested the thermostat which worked properly and was set at 73, and the room temperature measured 71.6-degrees F. R9 stated the AC unit can use some work because it gets too cold, and their medication makes them cold, so it is really cold. Additionally, during interviews with Residents R1-R10, were asked if the common rooms were kept at a comfortable temperature, ten (10) out of ten (10) stated common rooms are kept at a comfortable temperature. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Assistant Executive Director, Cecille Bernabe, and Business Office Director, Raul Pereira and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2024 · control 11-AS-20240709155106

Allegation investigated: Facility staff do not store cleaning chemicals locked and inaccessible to residents in care

On 03/19/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a complaint visit to the facility listed above. LPA met with Executive Director, Paul Gozon, and the purpose of today’s visit was explained. During today’s visit LPA toured the facility, interviewed Staff (S1-S7), interviewed Residents (R1-R8), and received documents pertinent to the investigation. The documents received and reviewed include the Staff Roster, Resident Roster, Relias training logs, and in-service training logs. The investigation revealed the following: Continued on LIC9099-C Unsubstantiated Allegation: Facility staff do not store cleaning chemicals locked and inaccessible to resident in care. It is alleged that in the memory care unit, cleaning products are left out on the counter or put in cabinet that is not secured and is accessible to residents. During the facility tour, LPA and the Executive Director toured the full Memory Care Unit. LPA observed that on all three floors of the Memory Care Building, each kitchenette had a locked cabinet under the sink where cleaning supplies are stored. LPA observed that all cleaning products were inaccessible to residents. Staff opened cabinet and LPA observed the only cabinet with cleaning supplies in it was the locked cabinet under the sink. Additionally, LPA checked the laundry room on each floor, and observed they were secured and locked. LPA observed housekeeping cleaning rooms on the first floor of the Memory Care and observed the cleaning chemical supplies box was locked at all times. LPA observed when the housekeeper needed a different product, they unlocked the box, put away what they had, took out what they needed, and locked the box again. During interviews with staff (S1-S7), were asked if they have received training's regarding the storage of cleaning chemicals, seven (7) out of seven (7) stated they have received training through Relias and In-Services regarding the storage of cleaning chemical. Additionally, seven (7) out of seven (7) stated that when not in use cleaning products are secured in a locked cabinet under the sink and are inaccessible to residents. During interviews with Residents (R1-R8), were asked if they have observed cleaning chemicals left out on the counter at any time, Continued on LIC9099-C eight (8) out of eight (8) stated they have not seen any cleaning supplies left out and accessible. During record review, LPA reviewed training logs for seven (7) staff, LPA observed seven (7) out of seven (7) had completed the Relias training regarding Chemical Safety. Additionally, LPA received and reviewed In-Service training logs, conducted on November 18, 2023 and March 7, 2024, regarding Chemical Safety and Maintenance of Supplies/Chemicals. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 11-AS-20240314085546

Allegation investigated: Neglect/Lack of Supervision resulted in severe injury.

On 02/10/24 Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Lifestyle Director (S4: Kathryn O'Brien). LPA conducted a risk assessment prior to entering the facility and observed COVID-19 protocol. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: An initial visit was conducted by LPA Jeremiah Randle on 08/24/22 with Executive Director/ Administrator (A1: Michele Johnson). LPA toured the facility and observed the facility to be in good condition. Residents were currently sitting in the common area engaged in social activities. Residents that were observed did not show signs of distress or abuse. (Evaluation Report continues LIC 9099-C) Unsubstantiated Currently there are 118 residents; of which, five (5) are non-ambulatory and sixteen (16) are receiving hospice care. LPA requested the following pertinent documents pertaining to the investigation: resident roster, staff roster, admission/memory care agreement (dated 08/04/22), power of attorney (effective 06/01/21), appraisal needs and services plan (08/04/22), physician report (08/02/22), level of care plan (dated 08/04/22), progress notes (from 08/18/22 – 08/26/22), private care agreement (dated 08/04/22), facility staff schedules (from 08/01/22 – 08/23/22), and incident report (dated 08/22/22). Due to the nature of the complaint, it was referred to the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD), Investigation Bureau (IB). Investigation Bureau (IB) accepted and assigned the full investigation to Investigator Heidy Bendana. The investigation included a review of medical records from Torrance Memorial Medical Center (dated 08/22/22); interviews with facility staff (A1, S1 – S3), residents (R1, R3, and R4), and witness (W1). IB Investigator Bendana did not interview Resident #2 (due to cognitive impairment) or Witness #2 (due to unavailability). The investigation revealed the following: Regarding Allegation #1: this investigation revealed based on Torrance Memorial Medical Center’s medical records that Resident #1 did not sustain a fracture resulting from an unwitnessed fall at the facility on 08/22/22 nor did the medical records for admission (dated 08/22/22) mention bruising or skin tears. A CT scan was conducted of the left hip with findings showing no acute fracture was identified. No definite fracture of the left femur was identified. CT was obtained to rule out acute fracture and all findings are consistent with an old injury. Prior to being admitted to the facility, Resident #1 went for a walk in their neighborhood and was found on the ground and transported to Torrance Memorial Medical Center ER for an unwitnessed fall on 07/17/22. Resident #1 complained of some left hip pain even though clinically suspicion of fracture/dislocation was low. X-ray of the left hip did not show acute abnormality. Resident #1 was discharged to Del Amo skilled-nursing facility on 07/19/22. On 08/10/22, Resident #1 was presented to the emergency department (ER) at Torrance Memorial Medical Center for evaluation of skin tears to the upper extremities after an unwitnessed fall from their bed at the skilled nursing facility. (Evaluation Report continues LIC 9099-C) Resident #1 accidentally slipped while getting out of bed and sustained skin tears to their upper extremities. Resident #1’s responsible person disclosed that Resident #1 has “sensitive” and “thin” skin which causes bruising and skin tears to occur easily with a longer healing period. Based on this investigation, Resident #1 was admitted to Clearwater at South Bay on 08/04/22, facility staff took preventative actions because of the unwitnessed fall incident on 08/22/22. Facility staff changed Resident #1’s bed, ordered an alarm that attached to the resident’s clothing to sound off when the resident got up, a sensor mat to alert caregivers when the resident gets up from their bed, caregiver rounds were more frequent at an hour time frame, and established a toileting routine which the resident is taken to the bathroom every two (2) hours. In addition, facility staff recommended and assisted in Resident #1 having a private caregiver (Witness #2) at night 02/07/24 (between 2100 hours to 0700 hours, seven days a week). During the day, Resident #1 is in the common area where the resident is under constant supervision. Based on the evidence gathered, interviews conducted, and medical records reviewed, 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 of Neglect/Lack of Supervision resulted in severe injury is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Lifestyle Director Kathryn O'Brien.the state’s words, verbatim · CDSS document, Feb 10, 2024 · control 11-AS-20220823144132

Type of visit: Required - 1 Year

On 11/18/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Paul Gozon/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, of which (13) may be bedridden. Delayed egress approved for memory care and transitional units. The facility is two building structures, one building is designated for Assisted Living and Memory Care residents and consists of two (2) floors and the other building consists of Memory Care residents and has three (3) floors. There are a total of (54) Assisted Living units and (55) Memory Care units’ rooms, kitchen, TV room, multipurpose room, business office, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room and four (4) outside patio with table and sufficient chairs and putting green. There's no body of water around the building. All outdoor and indoor passageways are free of obstruction. LPA Iniguez toured the physical plant with Health Services Director. There were no bodies of water or obstructions on the premises. A total of (12) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #105, #106, #107, #217, #213, #214, #115(M),#104(M), #103(M), #107(M), #105(M) and #102(M); call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°. Evaluation Report continues on LIC 809-C LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 9/6/23. Annual fire clearance performed on 9/30/2023. Working landline phones are available on-site. A review of (6) residents' service files, (6) staff personnel files were kept properly. (6) Medication Administration Records (MAR) were observed. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. Executive Director will email copy of liability insurance to LPA. Technical Advice notes given to Executive Director Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D pages) An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Executive Director/ Paul Gozon.the state’s words, verbatim · CDSS document, Nov 18, 2023