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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603606
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:03:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2024 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241112145228
FACILITY NAME:CLEARWATER AT GLENDORAFACILITY NUMBER:
198603606
ADMINISTRATOR:SAMPEDRO, TAMMIEFACILITY TYPE:
740
ADDRESS:333 W. DAWSON AVENUETELEPHONE:
(626) 885-0140
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:148CENSUS: 102DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Claudia Bauer Business DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee does not ensure facility is adequately staffed to meed resident's needs
Staff are not providing adequate laundry services for resident's
Staff leave resident's in urine soaked clothing for an extended period of time
Staff are not dispensing medications as prescribed
Licensee does not ensure enough staff are present to prevent inappropriate interaction between resident's
Facility did not report unwitnessed falls to authorized representatives
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Business Director Claudia Bauer and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 11/19/2024, LPA interviewed Staff #2 - Staff #9, Resident #1 - Resident #10, and toured the facility. LPA obtained copies of the following documents: staff roster, resident roster, SIR reports for unwitnessed falls, laundry schedule, receipts, and emails for dryer purchase. LPA obtained Individual service plan, progress notes and physician report for R6. During todays visit LPA Gutierrez checked medication and delivered findings.

SEE 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20241112145228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLEARWATER AT GLENDORA
FACILITY NUMBER: 198603606
VISIT DATE: 12/06/2024
NARRATIVE
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In regard to the allegation “Licensee does not ensure facility is adequately staffed to meet resident's needs”, it is alleged that due to the lack of staffing residents are not being changed timely when they use the restroom leading to UTI and that residents requiring 2/3 people assist are not being helped due to staffing issues. During interviews with staff eight (8) out of nine (9) staff stated that they have enough staff members. S5 stated “We are always fully staffed. If we ever feel like we are busy our MedTech step in to and help”. S6 stated “Yea we usually have three to four care partners per shift. I feel there is enough most of Assisted living are independent”. During interviews with residents seven (7) out of ten (10) residents feel there is enough staff to meet their needs. R5 did feel there is not enough staff and response time is to slow when pendants are pushed.

In regard to the allegations “Staff are not providing adequate laundry services for resident's and “Staff leave residents in urine-soaked clothing for an extended period of time” it is alleged that due to lack of staffing residents’ laundry is not being completed and resident are being left in urine-soaked clothing for extended periods of time. During interviews with staff eight (8) out of nine (9) staff stated that they have a laundry schedule they follow, and they do a diaper check every two hours. S4 stated that if the needs and service plan indicate there is an incontinence problem they check more often. During interviews with residents nine (9) out of ten (10) residents felt that their laundry always gets done in a timely manner and have never been left or witnessed any resident in a urine-soaked clothing. R9 did state that he/she witnessed a resident in a wheelchair asking staff to be changed. During visit LPA observed multiple washers and dryers in both the memory care unit and assisted living unit. LPA did a walkthrough of several rooms and did not witness any urine-soaked laundry.

In regard to the allegation “Staff are not dispensing medications as prescribed”, it is alleged that staff is not disposing medication as required. During interviews with staff six (6) out of nine (9) staff stated that all medication is given as prescribed. S6 and S7 had no knowledge of how medication is dispensed. S4 stated “Sometimes we have pharmacy medication on hold for insurance reasons if it’s not covered”. During interviews with residents eight (8) out of ten (10) residents stated they are getting there medication as prescribed. R5 expressed the only problem was at noon time for eye drops. R6 stated only when they are away at mass that there not given medication and marked as a refusal. LPA checked medication for memory care unit and assisted living unit and no discrepancies were found.

SEE 9099C

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241112145228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CLEARWATER AT GLENDORA
FACILITY NUMBER: 198603606
VISIT DATE: 12/06/2024
NARRATIVE
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In regard to the allegation “Licensee does not ensure enough staff are present to prevent inappropriate interaction between resident's”, it is alleged that R4 who resides in the assisted loving side constantly tries to enter the memory care unit and that R4 has been caught kissing another resident and walking resident to assisted living side without staff knowledge. During interviews with staff eight (8) out of nine (9) staff stated there are no inappropriate interaction between residents. Staff indicated that they are aware when anyone enters the memory care unit as they need to be let in. S4 stated” We don’t prohibit residents from interacting with each other unless there is a specific order for that”. During interviews with residents ten (10) out of ten (10) state there was nothing inappropriate going on between residents. R3 stated “No, they are very careful they know our names”. R4 stated “staff is aware and said I can go to the common areas just not the rooms. I understand that it is a safety concern”.

In regard to the allegation “Facility did not report unwitnessed falls to authorized representatives”, it is alleged that the facility has had several unreported falls and are not reported due to “too much paperwork”. During interviews eight (8) out of nine (9) staff indicated they always report falls. S8 stated “We report everything. I have never heard that”. Staff provided LPA with incident report for unwitnessed falls. During interviews with residents nine (9) out of nine (9) residents were unaware if staff reports falls.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was given to Business Director Claudia Bauer.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3