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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006040
Report Date: 08/23/2022
Date Signed: 08/23/2022 03:39:55 PM

Document Has Been Signed on 08/23/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CLEARWATER AT NORTH TUSTINFACILITY NUMBER:
306006040
ADMINISTRATOR:JENNIFER KORNMANNFACILITY TYPE:
740
ADDRESS:11901 & 11905 NEWPORT AVENUETELEPHONE:
(714) 656-9200
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 124CENSUS: 82DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Vice President of Operations Kathleen McCarronTIME COMPLETED:
03:45 PM
NARRATIVE
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2022 03:39 PM - It Cannot Be Edited


Created By: Michelle Reed On 08/23/2022 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLEARWATER AT NORTH TUSTIN
FACILITY NUMBER: 306006040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited
CCR
87464(f)(1)

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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
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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.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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