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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006040
Report Date: 09/19/2025
Date Signed: 09/19/2025 11:18:07 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250912152427
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: 114DATE:
09/19/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Health Services Director Jasmine BarajasTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff placed restrictions on residents right to have visitors and did not have privacy with visitors
INVESTIGATION FINDINGS:
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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 instructions to the facility to restrict certain visitors to R1 on September 10, 2025, and September 11, 2025, due to those visitors causing distress to R1 during their visit on September 10, 2025. CONTINUED ON LIC9099-C
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
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 2
Control Number 22-AS-20250912152427
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CLEARWATER AT NORTH TUSTIN
FACILITY NUMBER: 306006040
VISIT DATE: 09/19/2025
NARRATIVE
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LPA conducted an interview with R1's POA who confirmed that he gave instructions to the facility to restrict certain visitors to R1 on September 10, 2025, and September 11, 2025, due to those visitors causing distress to R1 during their visit on September 10, 2025. LPA reviewed R1's Advance Health Care Directive dated July 15, 2021. R1's Advance Health Care Directive states that R1's POA has sole discretion to limit or prevent visitations or contacts with any individual that distresses R1 or interferes with R1's treatment, once R1 becomes incapable of making her own decisions. LPA reviewed a note from R1's Primary Care Physician (PCP) dated November 20, 2024, which states that due to R1's dementia diagnoses, R1 was incapable of making her own decisions. Therefore, R1's Advance Health Care Directive is valid, and R1's POA has authority to make decisions and place restrictions over R1's visitations, as of November 20, 2024.

Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Health Services Director Jasmine Barajas and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2