Clearwater At North Tustin

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on May 28, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jennifer Kornmann. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff neglect led to resident sustaining pressure injuries. Regarding the allegation the following was revealed: During a follow up visit on May 16, 2024, the Primary Care Physician (PCP) for R1 noticed skin breakdown to right hip. On May 16, 2024, PCP ordered Wound Care. During the course of the interviews with the PCP, the PCP stated that in May he noticed a shallow hip and requested Home Health care for a Pressure Injury 2. Per PCP, the pressure injury was not due to neglect. During the investigation LPA reviewed the Physical and Occupational therapy visits dated April and May 2024 for R1. Per email dated May 17, 2024, the PCP orderRead the full finding— CDSS inspection report, January 7, 2026 · control 22-AS-20240528112916

On September 19, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Health Services Director Jasmine Barajas was notified via telephone and later arrived to assist with today's visit. Regarding the allegations that, staff placed restrictions on residents right to have visitors and did not have privacy with visitors, the following has been concluded: It was alleged that Resident #1 (R1) had restrictions on who was able to visit her and was not given privacy when she had visits on September 10, 2025, and September 11, 2025. LPA was unable to conduct an interview with R1 for this complaint due to R1 passing away on September 13, 2025. LPA interviewed four facility staff. Four out of four staff confirmed that R1's Power of Attorney (POA), provided instructioRead the full finding— CDSS inspection report, September 19, 2025 · control 22-AS-20250912152427

Licensing Program Analyst (LPA) Michelle Reed met with Administrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The complaint was investigated by the Department and consisted of interviews with Administrator, six of six staff, witnesses as well as documentation from the facility file. The following was determined: Resident #1(R1) was admitted into the facility on January 3, 2022. R1 had Cognitive Impairment and according to records reviewed needed minimal assistance with his activities of daily living. R1 was not a fall risk at the time of admission, was ambulatory and had fallen three times within a two week period. The first two falls were unwitnessed. On June 17, 2022 R1 was found on the floor with a wound on the back of neck and the second on June 22, 2022. The second fall caused a wound on the back of his head and a skin tear. 911 was contacted and R1 was sent to the hospital for evaluation. He returned to the facility with fall precautions put iRead the full finding— CDSS inspection report, March 22, 2023 · control 22-AS-20220708091818

Licensing Program Analyst (LPA) Michelle Reed met with Administrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The complaint was investigated by the Department and consisted of interviews with Administrator, six of six staff and witnesses as well as documentation from the facility file. The following was determined: Resident #1(R1) was admitted into the facility on December 27, 2021. R1 has Cognitive Impairment and according to records reviewed needs assistance with her activities of daily living. R1 was also a fall risk and had balance issues. R1 is non-ambulatory and uses a walker. Interviews disclosed that R1 had experienced multiple falls at the facility as R1 would attempt to use the restroom without assistance. The facility had a bed alarm for R1’s bed but R1 would sometimes turn the alarm off. On August 2, 2022 at approximately 7:15 a.m, R1 was discovered on the floor of her bathroom. Staff immediately took appropriate steps to assist R1 and cRead the full finding— CDSS inspection report, March 20, 2023 · control 22-AS-20220803151812

Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Administrator Jennifer Kornmann. The complaint was investigated and consisted of interviews with the facility staff, Administrator, and a review of Resident #1’s records. The following was determined: Resident #1 (R1) was admitted into the facility on 12/3/21. R1 resided in the Assisted Living building. On 8/11/22, at approximately 6:15am, R1 had an unwitnessed fall in his room. Staff immediately called 911 and R1 was taken to the hospital for evaluation. R1 did not receive any injuries. Records reviewed disclosed that R1 had a series of falls prior to 8/11. Based upon the interviews conducted and the records reviewed, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that R1’s falls were due to lack of supervision. An exit interview wRead the full finding— CDSS inspection report, March 20, 2023 · control 22-AS-20220811134259

Licensing Program Analyst (LPA) Jessica Cho made an unannounced complaint visit for the purpose to investigate into the above allegation. LPA met with Executive Director (ED) Jennifer Kornmann upon arrival and stated the purpose of the visit. During the course of the investigation, LPA completed a file review, obtained records for Resident 1 (R1), and interviewed the ED. The following are the findings which involved record review and interview: On the allegation that staff did not provide resident's authorized representative with all records, it was alleged that R1's progress notes for the first two months were not provided upon request. R1 was admitted on 04/29/2022 and departed from the facility on 08/25/2022. ED stated per interview that copies of records for R1 were picked up at the facility by the authorized representative on January 26, 2023. LPA observed per review of records that the progress notes started on 06/23/2022 and ended on 08/26/2022. LPA along with the ED reviewed thRead the full finding— CDSS inspection report, February 24, 2023 · control 22-AS-20230221154905