Inspection Reports for Clearwater at North Tustin

An unannounced visit was conducted to investigate a complaint alleging that staff placed restrictions on a resident's right to have visitors and did not provide privacy during visits.

The investigation found that the resident's Power of Attorney had valid authority to restrict visitors due to distress caused to the resident, and the complaint was determined to be unfounded.

The complaint alleged that staff restricted Resident #1's visitors and did not provide privacy during visits on September 10 and 11, 2025. The resident had passed away before the investigation. Interviews and document reviews confirmed that the Power of Attorney had authorized visitor restrictions due to distress caused by certain visitors. The complaint was found to be unfounded.

The inspection was an unannounced Required/Annual Inspection conducted to evaluate the facility's compliance with regulations.

The facility was found to be in compliance with no deficiencies cited. Observations included operable safety systems, adequate food supplies, proper medication storage, and well-maintained resident rooms and common areas. A technical violation was issued for water temperature exceeding the allowed range.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/08/2022 alleging that a resident suffered a fall resulting in serious injuries due to lack of care and supervision.

The investigation found that Resident #1 had multiple falls, including one on July 5, 2022, which resulted in serious injuries. Staff took appropriate steps to assist and call 911. The allegation of neglect or lack of supervision was deemed unsubstantiated due to insufficient evidence that staff caused or contributed to the fall.

The complaint was investigated through interviews with the administrator, six staff members, witnesses, and review of facility documentation. The allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.

An unannounced complaint investigation was conducted following a complaint received on 08/03/2022 alleging that a resident suffered a fall resulting in serious injuries due to lack of care and supervision.

The investigation found that Resident #1, who was a fall risk, sustained a fall resulting in a hematoma and broken clavicle. However, there was insufficient evidence to substantiate neglect or lack of supervision by facility staff. The allegation was deemed unsubstantiated.

The complaint was investigated through interviews with the administrator, six staff members, and witnesses, as well as review of facility documentation. The allegation of neglect or lack of supervision was unsubstantiated due to lack of definitive supporting evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/11/2022 alleging that a resident sustained multiple falls due to lack of supervision.

The investigation included interviews with staff and review of resident records. It was determined that the allegation was unsubstantiated as there was not a preponderance of evidence to prove the falls were due to lack of supervision.

The complaint alleged that Resident #1 sustained multiple falls while in care due to lack of supervision. The investigation found the allegation unsubstantiated.

An unannounced complaint investigation was conducted to investigate the allegation that staff did not provide the resident's authorized representative with all records.

The investigation found that the facility did not have progress notes for the first two months of the resident's stay, but all available progress notes were provided to the authorized representative. The allegation was deemed unfounded and dismissed.

The complaint alleged that staff did not provide Resident 1's authorized representative with all progress notes for the first two months. The allegation was investigated and found to be unfounded.

An unannounced complaint investigation visit was conducted following allegations that the facility did not have hot water, residents were not being bathed, and residents' laundry services were not being met while in care.

The investigation found that out of 9 rooms, 6 did not have hot water meeting regulation guidelines. End of shift reports and staff interviews confirmed that six residents did not receive showers and laundry services were not completed due to lack of hot water. The allegations were substantiated and posed immediate health and safety risks.

The complaint was substantiated based on water temperature measurements, interviews, and record reviews. The complaint control number is 22-AS-20220823133542. The complaint was received on 08/23/2022 and investigated with an unannounced visit on 11/01/2022.

The visit was an unannounced complaint investigation triggered by an allegation that a resident wandered away from the facility twice due to lack of supervision.

The complaint was investigated through interviews with staff, the administrator, and witnesses. The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

The complaint alleged that a resident wandered away from the facility twice due to lack of supervision. No dates or times were provided, and it was unknown if these incidents were related to prior citations for elopements. The complaint was found to be unfounded.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 07/11/2022 regarding lack of supervision resulting in a resident suffering a fall and injury.

The investigation found no supporting evidence of neglect or lack of supervision by facility staff that caused or contributed to the resident's fall. The allegation was determined to be unsubstantiated.

The complaint alleged lack of supervision resulting in a resident falling and sustaining injury. The investigation included interviews and record reviews. The allegation was unsubstantiated due to insufficient evidence to prove the violation occurred.

An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.

The facility was found to be in good repair with no deficiencies noted. Resident rooms and common areas were clean and safe, fire and safety equipment were operational, and COVID-19 mitigation plans were reviewed and found adequate.

The visit was conducted to follow-up on an elopement incident that occurred at the facility involving Resident #1 who left the facility unsupervised.

Resident #1 climbed over the side gate and eloped on 08/18/2022 without staff awareness, posing an immediate health and safety risk. The facility was cited for failure to provide adequate care and supervision.

The visit was conducted as a case management visit to discuss an Unusual Incident reported on 08/04/2022 involving a resident elopement from the Memory Care Unit.

Resident #1 eloped from the facility through delayed egress doors on 08/04/2022, the third such incident involving this resident within a 12-month period. Staff were unaware of the elopement until alerted by the resident's responsible party. The delayed egress doors have a delay in locking, and staff have been trained and reminded to secure doors properly.

The visit was complaint-related due to an Unusual Incident involving Resident #1 eloping from the Memory Care Unit on 08/04/2022. This was the third elopement incident involving the resident within the past year. Staff were unaware of the elopement until notified by the resident's responsible party. The complaint was substantiated with cited deficiencies.

Licensing Program Analyst Michelle Reed conducted an unannounced Case Management visit to follow up on an Exemption Denial for Staff #1.

Staff #1, previously denied exemption and removed from the facility, was found still working at the facility. The staff member was immediately sent home and is no longer associated with the facility. No citations were issued at this time pending further information.

An unannounced complaint investigation visit was conducted to investigate allegations regarding facility doors being a hazard and staff not providing adequate food service.

The allegation that facility doors are a hazard was deemed unsubstantiated after testing doors and reviewing records. The allegation that staff are not providing adequate food service was substantiated based on interviews, observations, and review of staffing schedules and records, revealing insufficient food service personnel and staff working outside their primary roles.

The complaint investigation was initiated based on allegations received on 05/18/2022. The allegation regarding facility doors being a hazard was unsubstantiated. The allegation regarding inadequate food service was substantiated. The investigation included interviews with residents and staff, review of facility and staffing records, and observations.

The visit was conducted to discuss two unusual incident reports sent to the Department on 3/17/22 and 3/28/22 involving residents wandering from the facility unassisted.

Residents R1 and R2 wandered from the community without staff supervision despite care plans indicating they cannot leave unassisted and have wandering behaviors. Both residents were found and returned without injuries, but this posed an immediate health and safety risk.

The investigation was triggered by two unusual incident reports regarding residents wandering unassisted. The complaint was substantiated as deficiencies were cited related to inadequate supervision of residents with wandering behaviors.

The visit was an announced pre-licensing inspection conducted to evaluate the facility's readiness for licensure following the application received on 2021-07-19.

The facility was found to be in compliance with regulations, including operational fire safety equipment, clean and operational resident rooms, secured medication rooms, and adequate emergency supplies. The facility meets Title 22 Division 6 of the California Code of Regulations and is ready for licensure.

Initial licensing evaluation conducted via telephone call to confirm applicant and administrator understanding of licensing requirements and program policies.

The applicant and administrator successfully completed the Component II evaluation, demonstrating understanding of facility operation, staff qualifications, program policies, and COVID-19 mitigation plan. No clients were in care at the time of the evaluation.