Clearwater at North Tustin

Allegation investigated: Resident suffered a fall resulting in serious injuries due to lack of care and supervision.

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 into place. On July 5, 2022 at approximately 11:45 am. Staff #1 witnessed R1 fall as he was entering his bedroom. Staff Unsubstantiated took appropriate steps to assist R1 and call 911. R1 was transported to the hospital. R1 sustained a pelvic and left humorous fracture and a laceration at his left eye. Based on the information gathered during the investigation, there was not definitive supporting evidence of neglect or lack of supervision on the part of Clearwater staff that caused or contributed to R1’s fall on July 5, 2022. The allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Kornmann and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 22, 2023 · control 22-AS-20220708091818

Allegation investigated: Resident suffered a fall resulting in serious injuries due to lack of care and supervision.

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 call 911. R1 was transported to the hospital. R1 Unsubstantiated sustained a hematoma on her forehead and a broken clavicle per incident report. Based on the information gathered during the investigation, there was not definitive supporting evidence or supporting witness statements to substantiate neglect or lack of supervision on the part of Clearwater staff. The allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Jennifer Kornmann and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2023 · control 22-AS-20220803151812

Allegation investigated: Resident sustained multiple falls while in care due to lack of supervision

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 was conducted and a copy of this report was provided to Jennifer Kornmann. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2023 · control 22-AS-20220811134259

Allegation investigated: Staff did not provide resident's authorized representative with all records.

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 the Yardi database system on the ED's computer which contains all... Unfounded digitized progress notes and verified that the facility did not have progress notes entered from 04/29/2022 to 06/22/2022. Therefore, the facility provided all progress notes that were available to the authorized representative. This agency has investigated the complaint and based on the observations made, interview that was conducted and the records reviewed, the above allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Jennifer Kornmann, and a copy of this report and the LIC811 were provided during this visit.the state’s words, verbatim · CDSS document, Feb 24, 2023 · control 22-AS-20230221154905

Allegation investigated: Resident wandered away from facility twice due to lack of supervision

Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of this complaint investigation. Upon arrival, LPA met with Administrator Jennifer Kornmann. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined: Anonymous Complainant alleges that unknown resident wandered away from the facility twice. No dates or times were provided as to when the alleged incidents took place. The facility was cited prior for elopements. It is unknown if this allegation is the same incidents. This agency has investigated this complaint alleging that a resident wandered away due to lack of supervision from staff. We have found that the complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.An exit interview was conducted and a copy of this report was provided to Administrator Jennifer Kornmann. Unfoundedthe state’s words, verbatim · CDSS document, Nov 1, 2022 · control 22-AS-20220817101613

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility does not have hot water Residents are not being bathed Residents laundry services are not being met while in care

Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of this complaint investigation. Upon arrival, LPA met with Administrator Jennifer Kornmann. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined: On 8/31/22, a tour of the Memory Care unit (Clearbrook) was conducted with Jennifer Kornmann. Hot water was tested in random resident rooms as well as the laundry room. Water temperatures were as follows: Room 137 102 degrees F Room 152 108.3 degrees F Room 130 100.4 degrees F Room 142 100.5 degrees F Room 118A 104.3 degrees F Room 139 102 degrees F Room 115 104.3 degrees F Laundry 106.8 degrees F Room 112- 106.3 degrees F Substantiated Out of 9 rooms, 6 rooms did not have hot water that met regulation guidelines. End of shift reports were reviewed and staff were interviewed. Shift reports for 8/24/22 -8/27/22 disclosed that Resident #1, #2, #3 ,#4 , #5 and #6, did not get their showers as there was no warm or hot water. Laundry services were also not completed during that time as there was no hot water. Based upon water temperatures at the time of the 8/31/22 visit, interviews, and a review of records the preponderance of evidence standard has been met and the allegations are substantiated. See LIC9099D for cited deficiencies. An exit interview was conducted and a copy of this report and appeal rights were provided to Ms. Kornmann.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 22-AS-20220823133542

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Nov 2, 2022

Maintenance and Operation-Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degrees F. This requirement was not met as evidenced by: On 8/31/22 hot water temperatures were measured in random resident rooms and the laundry room. Out of 9 rooms, 6 rooms did not have hot water that met regulation guidelines. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: Licensee agrees to immediately check water temperatures on a daily basis to ensure that it is in between regulation guidelines. Certification will be provided. Further investigation by Maintenance after initial visit on 8/31/22 concluded that there were issues with the condenser and valve. All has been repaired.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 2, 2022

Basic Services-Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.This requirement not met as evidenced by: End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22. Reports disclosed that Resident #1, #2, #3 ,#4, #5 and #6 did not receive their showers as there was no warm or hot water. This poses an immediate health and safety risk/ personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: Licensee agrees to check hot water temperatures and end of shift reports to ensure that all residents are being showered as agreed to by the Licensee in the residents admission agreements and or care plans. Certification of understanding will be provided.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(g)(1) · Plan of correction due date: Nov 2, 2022

Maintenance and Operation- Facilities which have washing machines shall: Have adequate supplies available and equipment maintained in good repair. This requirement was not met as evidenced by: End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22 and interviews were conducted with random staff. Laundry services were not completed due to no hot water. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: Licensee agrees to check all end of shift reports as well as the hot water temperatures to ensure that all residents laundry is being completed as agreed to in the residents admission agreements and or care plans. Certification will be provided.

Allegation investigated: Lack of supervision resulting in resident suffering a fall and sustaining an injury.

Licensing Program Analyst (LPA) Michelle Reed met with Adminsitrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The investigation consisted of interviews with Administrator, staff and witnesses as well as documentation from Resident #1's file. The following was determined: Resident #1(R1) was admitted into the facility on April 22, 2022. R1 had Cognitive Impairment and according to records reviewed needed assistance with his activities of daily living. R1 was ambulatory and walked with a cane as he was unsteady. On July 8, 2022, at approximately 8:20pm Staff #1 found R1 on the floor of his apartment. R1 complained of head, knee and arm pain. 911 was immediately called. R1 was transported to the hospital. R1 sustained blunt trauma and returned to the facility using a wheelchair. Based on the information gathered during the investigation, there was no supporting evidence of neglect or lack of supervision on the part of Clearwater staff that caused or contributed to R1’s fall. 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 the alleged violation occurred. An exit interview was conducted with Jennifer Kornmann and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 1, 2022 · control 22-AS-20220711174604

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Business Office Director Leo Serna and stated the purpose of this visit. Executive Director Jennifer Kornmann was unable to attend the inspection. The facility is a single-level structure divided into three zones, licensed for one hundred and twenty-four non-ambulatory residents with a hospice waiver for ten. Six may be bedridden. This facility offers Residential Care for the Elderly/Dementia. At about 9:15 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. The facility is divided into 3 zones. Each zone has common areas which include, dining area, art studio, club room, hair salon, wellness center and some storage units. Resident rooms were selected at random for inspection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did have private restrooms. Resident restrooms were observed to be in good repair and provided with grab bars and hot water was measured between 105.0 degrees – 119.8 degrees Fahrenheit. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 poster posted in a prominent location. Kitchen was in good repair and in a separate room inaccessible to residents. LPA toured the kitchen and saw they had a walk-in refrigerator and freezer. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. Fire alarms and carbon monoxide alarms were previously tested and received as passing score on 09/23/2022. For the exterior portion, facility had an outside patio with shaded seating and grounds were free of tripping hazards. LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. For this visit, no deficiency was noted in areas observed. LPA Tapia conducted an exit interview with Executive Director Jennifer Kornmann and copy of this report was explained and left at the facility.the state’s words, verbatim · CDSS document, Oct 24, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst Michelle Reed arrived at the facility to conduct a Case Management visit. The visit was conducted to follow-up on an elopement that occurred at the facility. Upon arrival, LPA met with Vice President of Operations Kathleen McCarron. Resident #1(R1) was admitted into the facility on 8/5/22. R1 resided in the Memory Care Unit (Clearbrook). On 8/18/22 at approximately 1:03pm R1 pulled a bench over to the outside exit gate and stood on it and climbed over the fence. Staff were unaware that he had left as they were assisting other residents. R1 was located in the parking lot just outside the Clearbrook building by Business Office Director and Maintenance Assistant and brought back inside. R1 was assessed with no injuries. R1 was later observed on the facility . R1's records were reviewed. R1 was not able to leave the Community without supervision due to cognitive impairment. See LIC809D for cited deficiency. An exit interview was conducted with Kathleen McCarron and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Aug 23, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 24, 2022

Basic Services-Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code. Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident's physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: On 8/18/22 R1 climbed over the side gate (eloped) and staff were not aware. R1 cannot leave the facility unassisted. This poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Aug 23, 2022

Plan of correction: Licensee agrees to provide enough staffing to meet the care and supervision of residents in care. A statement of understanding will be provided regarding this Basic Service. Civil penalties assessed.

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Michelle Reed arrived at the facility to conduct a case management visit. The visit was conducted to discuss an Unusual Incident that was reported to Licensing on 8/4/22. Upon arrival, LPA met Business Office Manager Leo Serna. Administrator Jennifer Kornmann arrived at approximately 9:30am. On 8/4/22 at approximately 2:50pm, Resident #1(R1's) exited the side door of the Memory Care Unit. Staff was unaware that she had exited. Staff were alerted by R1's responsible party when he arrived to take R1 to a medical appointment a little after 3pm. Upon notice, staff immediately began a search of the property and surrounding area. R1 was found at approximately 3:20pm by the Culinary Food Service Director. R1 was found 6 blocks away from the facility at Newport Ave and Foothill Blvd. R1 did not have any injuries and was taken to her medical appointment by her responsible party. This is not the first time R1 has left the facility, there have been 2 other elopements. The first was on 3/27/22 and the second on 7/24/22. All three elopements involved the delayed egress doors. During the second elopement R1 did not leave the property and was found outside by staff in the parking lot, According to Ms. Kornmann, there is a little bit of a delay for the doors to lock once the key pad is set. Camera's present did show R1 exiting the doors during the delay. Staff have been trained and reminded to ensure that the doors are secure before they walk away. There are also signs at the doors to remind staff to check the doors. At the time of this visit, LPA toured the Clearbrook Building (Memory Care). Delayed egress doors were operating and R1 was observed with a 1:1 care staff. Interviews were also conducted and records reviewed for R1. See LIC809D for cited deficiencies. An exit interview was conducted with Administrator Jennifer Kornmann and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 8, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Aug 9, 2022

Care of Person's With Dementia-Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by: On 8/4/22 R1 eloped from the Community via the delayed egress doors in the Memory Care Unit(Clearbrook). Staff were unaware that R1 had left the Community. This was not the first elopement through the doors by R1. R1 also eloped on 3/27/22 and 7/24/22.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: Administrator agrees to develop an elopement plan for R1 and ensure that staff are trained on the plan. Administrator further agrees to provide more frequent checks for residents who wander and to have enough staff to escort residents who leave the facility. A copy of the plan will be provided to the Department. This deficiency was a repeat violation within a 12 month period and civil penalties are assessed.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michelle Reed conducted an unannounced Case Management visit to the facility. LPA met with Administrator Jennifer Kornmann to follow up on an Exemption Denial for Staff #1. On 3/26/22, the Department issued an Exemption Denial for Staff #1. On 3/28/22 Executive Director Tammy Sampedro signed and sent the Confirmation of Removal letter to the Department indicating that Staff #1 had been removed from the facility. Today, 7/12/22, Executive Director Jennifer Kornmann informed LPA that Staff #1 was still working at the facility. Ms. Kornmann immediately sent Staff #1 home upon her arrival to work. It is unknown at this time if an appeal was filed. S1 is no longer associated to the facility. No citations at this time pending further information. An exit interview was conducted and a copy of this report was given tothe state’s words, verbatim · CDSS document, Jul 12, 2022

Allegation investigated: Facility doors are a hazard

Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to investigate the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Jennifer Kornmann and explained the purpose of the visit. On today's visit. LPA Velazquez conducted interviews with residents and staff. During the course of the investigation LPA Velazquez reviewed and obtained copies of facility, staff, and resident records. LPA also conducted interviews with residents and staff. The individuals interviewed provided conflicting statements and could not corroborate the allegation. The records reviewed included a proposal from Vortex dated May 25, 2022 for the delivery and installation of Quad 7000 Low Energy Door Operators that meet ADA guidelines, and staff email communication documenting the Vortex proposal and approval by staff. LPA also reviewed Unsubstantiated work shifts, resident and staff rosters. The current staffing agencies utilized by the facility are Concierge Senior Services and Angel Connection. LPA Velazquez also conducted interviews with staff and residents who were able to corroborate the allegation. Some staff indicated they assisted wherever they were needed and worked as dining room servers which was not their primary role in the facility. Other staff indicated they worked excessive hours due to the lack of staff present such as a dishwasher. Some residents indicated they had to wait an extended period of time for their meals or desserts to be served due to the lack of servers present. On one occasion a staff member indicated they were the only server to cover the dinner shift. Direct care staff known as Care Partners have their work schedules divided between providing care and supervision directly to residents and then are also scheduled to work as servers which is not their primary role in the facility. LPA Velazquez observed this Care Partner work as a server with their name badge clearly identifying them as a Care Partner. This Care Partner also indicated that on that particular day there was no one to cover their shift as a Care Partner which left the direct care staff understaffed. The resident records reviewed included Physician's Reports, Care Plans, Care Pricing which documented the levels of care and corresponding fees, North Tustin Health and Service Evaluation Results, and Admissions Agreements. Based on the observations made, interviews which were conducted, and the records reviewed, the preponderance of evidence standard has been met, therefore the allegation of Staff are not providing adequate food service is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099 D. An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the appeal rights, LIC 9098 and LIC 811s were provided at the time of this visit. resident records which included Physician's Reports, North Tustin Health and Service Evaluation Results, and Admission Agreements. LPA Velazquez along with the Maintenance Director tested several doors throughout the facility that all meet ADA guidelines. 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 following allegation: Facility doors are a hazard is deemed UNSUBSTANTIATED. An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the LIC 811s were provided at the time of this visit.the state’s words, verbatim · CDSS document, Jul 7, 2022 · control 22-AS-20220518102354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Jul 28, 2022

General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by: based on observation and interviews the licensee did not employ sufficient food service personnel which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2022

Plan of correction: Licensee to ensure sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents at all times. Licensee to submit written proof of correction to LPA by POC due date indicating exactly how they will adhere to this regulation.

Type of visit: Case Management - Incident

Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management. The visit was conducted to discuss two unusual incident reports sent to the Department on 3/17/22 and 3/28/22. Upon arrival, LPA met with Administrator Tammie Sampedro. A tour of the Clearbrook Building (Memory Care) was conducted and records were reviewed for Resident #1 and Resident #2. On 3/10/22 R1 was admitted into the Community. According to records reviewed R1 resides in the Assisted Living Building. R1 cannot leave the facility unassisted and according to her care plan, has a history of wandering behavior. There was a wander guard put in place, but R1 took it off. On 3/11/22 at approximately 7:30 am, R1 was outside the front door trying to get back in to the building. The Concierge arrived for work and let her inside. At approximately 9:15am the Concierge received a call from the Sunrise Community down the street (quarter of a mile) that R1 was at their building trying to come inside. The police had been called and R1 was returned to the Community. On 3/12/22 R1 left the Community again, and the Maintenance Director brought her back. R1 was down the street from the building. He saw her down the street from the building on his way into work. R1 had also expressed wanting to hurt herself. R1 currently has a 1 on 1 caregiver and was seen by her doctor. R1 did not receive any injuries. On 3/27/22 at approximately 5:45pm, R2 could not be found in the Memory Care building. A search of the building as well as the Assisted Living was conducted and law enforcement was contacted. R1 was found down the street in the area of Newport and 17th Street by staff and law enforcement and returned to the Community with no injuries. R1 was placed on frequent status checks. See LIC809D for cited deficiencies. An exit interview was conducted with Administrator Tammie Sampedro and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Apr 5, 2022

Care of Person's With Dementia-Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by: R1 and R2 wandered from the Community without staff supervision. According to records reviewed they cannot leave the facility unassisted and have wandering behaviors. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2022

Plan of correction: Administrator agrees to provide more frequent checks for residents who wander. Administrator states they are currently using a staffing agency and are in the process of trying to hire more staff. Staff will also be trained on elopement behaviors and procedures. Proof of correction will be provided via agenda and sign in sheet.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Jerome Haley and Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. The Agency received the application for Licensure on 7/19/2021. LPAs were greeted and granted entry by facility staff and completed a Covid-19 screening upon entering the facility. President Danielle Morgan and Executive Director Tammie Sampedro led us on a tour of the facility. LPAs observed all staff wearing masks. Facility is to operate an Adult Residential Facility for the Elderly (RCFE) with a capacity of 124 of which 118 can be non-ambulatory, 6 bedridden. LPAs observed the facility has the PUB 475 poster (See Something Say Something) 20 X 26 inches, that will be mounted in the front lobby of the facility. Staff reported the Council on Aging poster (Ombudsman) poster has been ordered and will be mounted in the front lobby area. Structure; Facility is composed of 2 one story buildings, Assisted Living which has 72 resident units and Memory Care which has 28 resident units. LPAs observed no obstacles or hazardous in the facility. There was a variety of different rooms in the assisted living portion of the facility: a game room equipped with a pool table, wellness center for fitness and physical therapy, beauty salon and multipurpose theater room, and a creative arts studio. LPAs observed first aid kits in the employee only cleaning storage closets and the medication room. LPAs observed all fire extinguishers are charged. Bathrooms in the resident bedrooms were clean and operational and hot water measured 112.6 degrees Fahrenheit to 121.6 degrees Fahrenheit. Hot water temperature was set to 120.0 degrees Fahrenheit during the visit. Resident Bedrooms; LPAs inspected all resident rooms. Smoked detectors/Carbon Monoxide detectors tested operational. Pull cord signal system is operational. LPAs observed two rooms that were set up with model furnishings. All bedrooms had enough space to accommodate resident belongings. Resident rooms are unfurnished. LPA informed applicants that the facility is required to provide furniture to include, bed, night stand, lamp and chair, in good working order for residents who require it. Applicants stated they understood. All 4 Delayed egress exit doors in Memory Care are operational. Kitchen; LPA Jerome Haley inspected the kitchen. The refrigerator and freezer were operational and there were temperature logs posted on the refrigerator and freezer doors. Facility a has non-perishable food supply on hand as well as an emergency supply of food and water. Dining Room; is clean and organized and has enough space to accommodate the residents and is large enough to promote social distancing. Medication Room; LPAs observed the medication room is secured and in accessible to residents in care. Assisted Living and Memory each have their own medication room and medication carts to assist resident with the administration of medication. Exterior Grounds; LPAs inspected the exterior of the facility and there were no obstacles or hazardous. There were no bodies of water found. There was a main courtyard with shaded seating and dining areas, a BBQ area, and dog park. The exterior of the memory care also has shaded sitting areas. Fire Clearance: was approved by Santa Ana Fire Department Inspector Ryan Aloi on 11/17/21. Phone/Email: Facility phone number is 714.656-9200 email address is tammie.sampedro@clearwaterliving.com. Facility has submitted the emergency disaster plan and Covid-19 mitigation plan. Facility meets Title 22 Division 6 of the California Code of Regulations. Facility is ready for licensure. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was waived, applicants operate other licensed facilities that are in compliance. An exit interview was conducted and a copy of this report, LIC809 was explained and provided.the state’s words, verbatim · CDSS document, Nov 22, 2021

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 124 Census (if any clients in care): NO Method: Telephone call with CAB COMP II Participants: DANIELLE MORGAN & TAMMIE SAMPEDRO Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1.Facility operation: License type, client/resident populations, and program 2.Staff qualifications and responsibilities 3.Applicant and Administrator qualifications 4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5.Grievances, Complaints, Community resources 6.Physical plant, food service 7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Nov 4, 2021