Clearwater at South Bay.

Allegation: Licensee did not abide by the admission agreement The allegation alleges that the licensee did not abide by the admission agreement by not disclosing all fees and charges. During record review, LPA received and reviewed residents R1 and R2’s Residence and Care Agreement, signed and dated 10/01/2025 by R1, that states “This Agreement shall be effective as of 09/30/2025.” Additionally, LPA received and reviewed the Move-In Prorate Worksheet -AL/MS signed and dated on 09/30/2025 by R1, that indicates R1 and R2 were prorated for September 2025 and was charged for one (1) day. During interviews with Staff S1-S5, they were asked if the move-in incentive and billing is explained to potential or new residents, five (5) out of five (5) stated it is explained and broken down based on the selected apartment, services they sign up for, and level of assistance required. Additionally, Staff S1-S5 were asked if fees and conditions are listed on the Admission Agreements, five (5) out of five (5) stated yes, fees and conditions are listed in the Residence and Care Agreement. During interviews with Residents R1-R12, they were asked if they were offered an incentive when they moved in and if the incentive was honored, five (5) out of twelve (12) stated yes, they were offered an incentive to move in, and it was honored. Three (3) out of twelve (12) indicated no they were not offered an incentive, or they were not sure. Four (4) out of twelve (12) declined to be interviewed. Resident R1-R12 were additionally asked if the pricing for lodging, assistance, and services were explained to them and listed in the Residence and Care Agreement, eight (8) out of twelve (12) stated yes it was explained to them, and it is listed. Four (4) out of twelve (12) declined to be interviewed. Additionally, during interviews with Residents R1-R12, they were asked if they have been charged a fee or service charge for a service they did not receive, eight (8) out of twelve (12) stated they have not been over charged. Four (4) out of twelve (12) declined to be interviewed During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Apolinario ‘Paul’ Gozon, Executive Director, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff did not allow residents to select their hospice provider It is being reported that the facility is restricting the ability of residents and families to choose their own hospice care. On 2/4/26, LPA Felisa Shirley requested the list of residents currently using hospice providers. LPA Shirley received a list of 8 residents, 2 residing in Assisted Living and 6 residing in Memory Care. During the investigation, LPA Shirley requested information regarding the hospice services the company uses. LPA Shirley received information packets from 11 different hospice providers. LPA Shirley observed that residents are utilizing varied hospice care providers. Per interview with S-2 on 2/4/26, Clearwater provides families with resources to make informed decisions about hospice care options. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed witness 1 – witness 4 (W1 – W4). Of those who interviewed 4 out of 4 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not allow residents to select their hospice provider,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Paul Gozon.

On 12/23/2025 at 8:31, Licensing Program Analysts (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Executive Director, Apolinario ‘Paul’ Gozon, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. The facility has been approved for delayed egress in the memory care and transitional units. Physical Plant/Structure The facility is located in a commercial area. It consists of two buildings, one building is designated for Assisted Living and Memory Care residents and has two (2) floors. The additional building is for Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business offices, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room, and five (5) outside shaded patio areas with tables and chairs. LPA did not observe any bodies of water on the premises. LPA observed all walkways and passages outside the facility to be clean, clear, and free of obstructions, debris, and hazards. Resident Rooms During the facility tour, LPA inspected ten (10) resident apartments and observed them to be clean and in good repair. The resident rooms inspected were rooms 105, 109, 206, 307, 310, 113, 120, 205, and 225. Resident’s apartments are furnished with their personal furniture. LPA observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPA observed beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the residents, but the facility does have a storage room with linens, and blankets in case a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPA observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPA observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for residents’ use. LPA observed the multipurpose/activity room to have tables and ample chairs. LPA observed an ample supply of arts and craft supplies available for resident use. The activity schedule was posted outside the door. The dining room had multiple tables and chairs to accommodate residents. LPA observed snacks and drinks are available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms, walkways and hallways in the facility were observed with ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. Kitche n LPA inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPA observed all appliances to be in good working repair. LPA observed an ample supply of cookware, dishware, and cutlery in good repair. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPA reviewed the temperature logs for the freezer and the refrigerator. LPA observed the monthly menus posted in the dining room and at the entrance of the dining room. LPAs observed all cleaning supplies secured in a locked storage room and are inaccessible to residents. Safety LPA observed multiple fully charged fire extinguishers last serviced on 10/20/25. The last annual fire inspection was conducted on 09/19/25. LPA observed smoke detectors and carbon monoxide detectors to be operational. LPA received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E) last updated on 01/16/2025. The last Emergency Drill was conducted on 10/16/25. The facility does have a working landline telephone. LPA observed all required posting throughout the facility. LPA reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators. Medications LPA observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original containers. LPA reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten (10) out of ten (10) residents’ MARs and medications are consistent with properly documented records. Files LPA reviewed ten (10) resident files and found they contained the required documents. LPA reviewed the Administrator and six (6) staff files and found they contained the required documents, clearance, certification, and training. LPA received and reviewed a copy of the Liability insurance through Acord valid till 11/11/2026. During file review, LPA observed the Licensing Fees are current. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Infection Control LPAs observed multiple hand sanitizing stations throughout the facility. LPAs observed an ample supply of hand soap and paper towels. LPAs observed required infection control signs posted throughout the facility. LPAs observed a 60-day supply of Personal Protective Equipment (PPE). During today's visit, LPAs did not observe or cite any deficiencies. An exit interview was conducted with Business Office Manager, Raul Periera and a copy of this report was provided.

Allegation: Staff did not ensure air conditioner was working properly The allegation alleges the facility is not kept at a comfortable temperature and the air condition is not working properly. During record review, LPA received and reviewed invoices from C&M Mechanical dated 05/29/2025, 07/09/2025, 07/25/2025, 08/12/2025, 08/15/2025, and 08/29/2025. During the visit conducted on 08/29/2025 the technician inspected all rooms with temperature complaints to verify the status of fan coils. The technician found no error codes on the AC units specified rooms. The technician observed that the fan coils in all rooms with temperature complaints were turned off at the thermostats. Additionally, the technician observed some of the rooms had open windows and blinds, contributing to the heat issue. During the visit on 08/12/2025, the technician observed the fan coil seemed closed due to pipe temperature not changing in rooms 207, 203, and 201. Room 101 had closed ports. The technician observed a loose not on ball valve. The technician tightened the nut and made sure the ball valves were opened. On 08/05/2025, 08/08/2025, and 08/12/2025 filters were changed, and the condenser coils were checked and cleaned. On 07/25/2025, the technician checked room 204 whose thermostat was set to off, when turned on, the thermostat setting was on heating. It was switched to cooling, then functioned properly. The technician checked Room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 07/09/2025, the technician checked room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 05/29/2025, room 107 had an error code. The technician changed the main PCB board, and the error cleared. In room 112 the motors were going bad. The technician changed the motor and the main PCB board for fan coil. On 05/06/2025, the technician checked the main units on the roofs. The technician observed one unit was not getting power due to the breaker not fully in the on position. The technician conducted a diagnostic and did not find any additional issues. During the facility tour, LPA took the temperature of all common areas and eleven resident rooms. The following temperatures were recorded in the assisted living lobby the temperature measured 74.3-degrees, the dining room measured 73.6-degrees, the activity room measured 72.1-degrees, the first-floor hallways measured 75.3, 73.2, and 74.3-degrees, and the second-floor game room measured 75.6-degrees Fahrenheit. The following rooms temperature was measured in the assisted living, room 103 measured 75.5-degrees, room 108 measured 76.4, room 209 measured 77-degrees, room 215 measured 76.6-degrees, 235 measured 77.3-degrees, and room 242 measured 70.7-degrees Fahrenheit. The following temperatures were measured in the Memory Care Unit, the hallway measured 75.2-degrees, the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 dining room measured 73.0-degrees, and the activity area measured 76.1-degrees. The following rooms temperature was measured in the memory care unit, room 117 measured 76.6-degrees, and room 118 measured 73.7-degrees Fahrenheit. The following temperatures were measured in the Clearbrook building first-floor common area measured 73.2-degrees, the second-floor common area measured 74.3-degrees, and the third floor measured 71.6-degrees Fahrenheit. LPA observed all resident rooms have a thermostat to control the temperature in their room. LPA observed thermostats accessible in common rooms. During interviews with Staff S1-S8, were asked if there have been any issues with the air conditioning in the building, two (2) out of eight (8) stated there was an issue with one of the units that has been repaired. Additionally, during interviews with Staff S1-S3, were asked if the HVAC system is maintenance, three (3) out of three (3) stated it is maintenance quarterly. During interviews with residents R1-R10, were asked if the air conditioning is functioning properly in their room, eight (8) out of ten (10) stated there are no issues with their air conditioning. Additionally, residents R1-R10 were asked if the facility is maintained at a comfortable temperature, ten (10) out of ten (10) stated the facility is kept at a comfortable temperature. Three (3) residents stated the activity room can get too cold. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

The investigation revealed the following: Allegation: Staff are not ensuring all staff are criminally record cleared The complaint alleges that “applicants are being hired and are being scheduled on the floor before having and passing a live scan and physical/medical testing.” On 07/10/25, at 9:30am, LPA Lee interviewed the Executive Director (A1) who denied the allegation stating that all applicants are criminally and medically cleared before they are able to work on the floor. On 7/10/25 at 10:30am LPA interviewed the Business Office Director (S1) who denied the allegation stating that he personally makes sure all applicants are criminally and medically cleared before hire. On 7/10/25, LPA reviewed the staff roster/schedule (6/23/25), and cross checked with the Department’s Personnel Report Summary (LIS) and did not observe any discrepancies On 7/10/25, LPA reviewed 10 staff files (S2-S11) and of those reviewed, 10 out of 10 had all required criminal clearance and medical clearance documents including TB/chest X-rays. Each staff file reviewed was in compliance with Title 22 regulations and had the required documentation. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation that Staff are not ensuring all staff are criminally record cleared. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Exit interviewed conduct and report provided to Executive Director, Paul Gozon. No deficiencies cited during today's visit. Page 2 of 2

On 06/26/2025 at 9:46 PM, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to deliver an Immediate Exclusion of a staff. LPA met with Executive Director, Paul Gozon, and the purpose of today's visit was explained. LPA was granted entry into the into the facility. During today's visit LPA delivered an Immediate Exclusion Letter for Daniel Castro due to conduct inimical. Daniel Castro is not to have contact with clients and cannot be physically at the facility. Daniel Castro was not present at the facility during time of visit. LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

Allegation: Staff have not provided authorized representative a copy of residents’ file. The complaint allegation alleges that a resident’s authorized representative has requested a copy of the residents’ rental agreement and visitor logs and have not received them. During a record review the Department received and reviewed Residents R1 and R2 Heath Information Release Authorization, dated 03/22/2023, that states Resident’s son or daughter are authorized to receive all medical records. Additionally, the department received and reviewed R1 and R2’s California Uniform Statutory Power of Attorney dated 10/23/2017, that allows the son and daughter to act as agents with the powers in California Probate Code Sections 4400-4465. The department received and reviewed a Durable Power of Attorney dated 07/23/2024 for R1 and R2 naming their daughter and son as appointed Power-in-Fact. Both documents give the daughter and son the authority to make decisions for their parents regarding finances and property. During interviews with Staff S1-S12, were asked if a resident’s representative requested documents regarding their resident how long does it take to process their request, four (4) out of twelve (12) stated it could take 24-hours to a week to processes that request. Additionally, Eight (8) out of twelve (12) stated they are not sure how long it would take, and they would instruct the residents authorized representative to speak to S2 regarding the request. Additionally, S1 stated they sent all the documents to the daughter that were requested. During interviews with Residents R3-R11, were asked if their family has requested documents from the facility and if they received the documents requested, five (5) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 out of nine (9) stated their family got documents right away. Additionally, four (4) out of nine (9) stated they have not requested any documents from the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Due to staff neglect, resident sustained a wound. The complaint allegation alleges that a resident was observed with an abscess from an unknown cause. During record review the department received and reviewed discharge paperwork from Torrance Memorial Hospital dated 08/15/2024. On 08/12/2024 R1 was admitted to Torrance Memorial Hospital and discharged on 08/15/2024, on the discharge paperwork the department did not observe any indication of an abscess. R1 returned to the facility with a private caregiver till they were transferred to a skilled nursing facility. On 08/18/2024, R1 was admitted to Berkley Post-Acute for physical therapy and occupational therapy. On 08/23/2024, R1 was prescribed Bactrim DS Tablet 800-160 MG for abscess on pubical area. The Transfer/Discharge Report from Berkley Post-Acute dated 08/26/2024 on diagnoses listed is “other specified dermatitis.” The discharge summary from Berkley Convalescent Hospital dated 08/26/2024 indicates R1 has a wound on the groin area. The facility provided a document for Outside Agency Documentation dated on 09/03/2024, AllCare Home Health conducted a visit for Wound Care on the groin. The department received and reviewed a prescription order, dated 08/28/2024, for Mupirocin, an ointment to be applied to an abscess for the groin. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The department received and reviewed the electronic Medication Administration Record (eMAR) for R1 for the months on August and September 2024 that indicates the cream was applied three (3) times a day as prescribed. During interviews with Staff S1-S12, were asked if any residents have sustained a wound due to neglect such as being left in soiled diaper for an extended period of time, or lack of hygiene care, twelve (12) out of twelve (12) stated no, they have no knowledge of a resident sustaining wounds due to neglect. During interviews with Resident’s R3-R11, were asked if they have sustained a wound due to neglect, nine (9) out of nine (9) stated they have not sustained injuries due to neglect. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Staff are double diapering diapers. The complaint allegation alleges that resident was placed in double diapers overnight. During record review the department received and reviewed In-Service Training Log and material used in the training conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 12/01/2023. The policy stated, “incontinence products should be used, if appropriate, and the resident’s incontinence product should be changed as needed.” During interviews with Staff S1-S12, were asked if residents are placed in double diapers, twelve (12) out of twelve (12) stated no residents are placed in double diapers. Additionally, staff S1-S12 were asked if they have heard of a residents placed in double diapers, eleven (11) out of twelve (12) stated they have not heard that from a resident or a resident’s family. S2 stated R2’s daughter informed them that R2 was observed with double diapers on two (2) occasions. S2 stated it was addressed right away with the staff and an In-Service Training was conducted to ensure it did not happen again. During interviews with Resident’s R3-R11, were asked if they have been placed in double diapers, nine (9) out of nine (9) stated they have not been placed in double diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Allegation: Staff left resident in soiled diapers. The complaint allegation alleges that resident is left in soiled diapers. During file review at the facility, the department received and reviewed a copy of the Care Partner Job Description that states care partners need to frequently check to 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 see if incontinent residents need changed. Additionally, the department received and reviewed In-Service Training Log and material used conducted on 09/18/2024. One of the topics discussed and reviewed during the in-service was “Toileting/Incontinence.” The training material used for the in-service was from the Memory Support Policy and Procedure Manual-CA titled Resident Toileting and the policy was last updated on 12/01/2023. The policy states staff will “Initiate toileting at least every two (2) hours and prior to typical “pattern” time. During an interview with the Administrator S1, was asked how often residents are assisted with incontinence, S1 stated residents are assisted every two (2) hours and some residents do require additional checks due to increased urine output from medications or fluid intake. During interviews with Staff S2-S12, were asked how often incontinent residents are assisted with changing, eleven (11) out of eleven (11) stated residents are assisted with changing every 2 hours if not more. During interviews with Residents R3-R11, were asked if they have been left in soiled diapers for an extended period of time, nine (9) out of nine (9) stated they have not been left in soiled diapers. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today's visit the department did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

facility, interviewed Residents (R1-R6), interviewed Staff (S6-S9), and received documents pertinent to the investigation. The documents reviewed and received include Staff Roster, Resident Roster for Memory Care Unit, Staff Training Logs of 100 modules Dementia Care and 10 modules on Falls, Resident Admission Agreement, Physician Reports, Communication Logs, and Safeguard of Property. During an additional subsequent visit conducted on 08/29/24, LPA met with Assistant Executive Director/Memory Care Director, Cecille Bernabe and Office Business Manager, Raul Pereira. During the visit, LPA toured the facility, interviewed Staff S2, and received documents pertinent to the investigation. The documents received and reviewed include Unusual Incident/ Injury Reports (SIR)s, Outside Agency Documentation, Skin Integrity Monitoring Form, Internal Occurrence report, and resident Hospital Discharge paperwork. The investigation revealed the following: Allegation: Staff did not safeguard resident’s personal items The complaint allegation alleges resident’s personal items such as clothes and tooth brush have gone missing. During the facility record review, LPA received and reviewed a copy of the Client/Resident Personal Property and Valuables (LIC621) for sis residents. LPA observed six (6) out of six (6) residents declined to fill out the form. During review of residents Admission Agreement, LPA observed in Appendix K Safeguard of Resident Property on page 2 states “the facility shall not be liable for items which have not been requested to be included in the inventory or for items which have (2A) Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 been deleted from the inventory.” During interviews with Staff S1-S8, were asked how the facility safeguards residents personal belongings, eight (8) out of eight (8) stated they encourage residents to keep personal belongings in their room and to lock their door when they leave their rooms. During interviews with Residents R1-R6, were asked if they had any items go missing, six (6) out of six (6) stated they have had no items go missing. Allegation: Staff did not document or report incidents to resident’s authorized person The complaint allegation alleges the responsible person was not notified of residents falls or injuries. During record review of Resident R1’s Progress Notes, LPA observed staff called the responsible party to inform them of incident’s that occurred on the following dates: 08/21/23, 09/20/23, 11/10/23, 12/14/23, 12/22/23, 12/29/23, and twice on 12/30/23. LPA observed messages were left on 12/29/23 and 12/30/23 until they were able to get in contact with the responsible party. LPA observed in the notes when they called a number for the responsible party, they kept getting a message stating the phone was waiting to connect, and the phone is unavailable. Additionally, LPA observed in the notes the staff left a message on an alternative phone number listed. In which, staff was informed by the responsible party that they were no longer using the number where they messages were left. During interviews with Staff S1-S8, were asked if residents responsible party is (3A) Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 notified if a resident has a fall or sustains an injury, eight (8) out of eight (8) stated the responsible party is notified of a residents fall, injury, or change of condition as soon as possible. During interviews with Resident R1-R6, were asked if their responsible party is notified of any fall, injuries, or change of condition, six (6) out of six (6) stated their family is notified of falls and injuries. Allegation: Staff did not provide activities for residents The complaint allegation alleges staff do not provide activities for the residents. During records review, LPA Iniguez observed copies facility activities calendar from October, November, and December 2023. During a tour of the facility, LPA Gibbs and Iniguez observed activities being performed to the residents in care. In addition, posting of daily activities is available in the common areas accessible to residents in care. During an interview with administrator (S#1) he stated that the facility offers activities for residents in care. During interviews with residents (R#1-R#6) (6) out of (6) stated that the facility provides activities. During an interview with facility staff (S#2-S#9) eight (8) out of eight (8) stated that the facility offers activities for residents in care, if they would like to participate. Allegation: Staff mismanaged resident medication The complaint allegation alleges that the Med Tech was unavailable when the family of a resident requested a PRN medication. During records review, LPA Iniguez observed copies of memory care Med Tech medication training logs. In addition, LPA Iniguez observed staff received training (4A) Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 concerning emergency events in their Relias modules. During a tour of the facility, LPAs Gibbs and Iniguez observed Med Techs in the Towers main medication room on the first floor. LPAs reviewed six (6) residents’ medication and electronic Medication Administration Record (eMar) and observed six (6) out of six (6) residents eMAR’s and medication are consistent with properly documented records. During an interview with administrator (S#1) he stated that the facility staff is trained regarding first aid assistance. During interviews with residents (R#1-R#6) six (6) out of six (6) stated they receive their medication when prescribed and PRNs when needed. During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated residents are given their medications as prescribed and follow procedure for PRN medications. Allegation: Staff do not safeguard confidential information The complaint allegation alleges that resident’s information and confidential information is not kept in a safe place. During the facility tour, LPAs Gibbs and Iniguez observed resident’s medical files secured in the locked medication room. Additionally, during the tour, LPAs observed residents’ facility documents secured in the locked business office managers office. During interviews with Staff S1-S8, were asked how they keep residents personal information safeguarded, eight (8) out of eight (8) stated personal files for the resident are locked in the medication room and the office. Additionally, eight (8) out of eight (8) stated they do not provide any information to any person other than the (5A) Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 residents responsible party, physician, home health, or hospice representative. During interviews with Residents R1-R6, were asked if the facility safeguards their personal information, six (6) out of six (6) stated the facility safeguards their information. Allegation: Staff do not provide utensils for residents The complaint allegation alleges that residents are given their meals without utensils and residents eat their food with their hands. When LPA’s Iniguez and Gibbs arrived at the facility the residents were having breakfast and LPAs observed residents were provided with utensils. Additionally, LPA’s observed lunch being served to residents in the Tower and utensils were provided. During the facility tour, LPAs observed an ample supply of utensils in the kitchen. During interviews with Staff S1-S8, were asked if residents are provided with utensils during meals and snack, eight (8) out of eight (8) stated residents are provided with utensils. During interviews with Residents R1-R6, were asked if they are provided with utensils during meals, six (6) out of six (6) stated yes, they are provided with utensils for meals. Allegation: Staff are unable to communicate with residents The complaint allegation alleges that staff are unable to communicate with residents. During records review, LPA Iniguez observed that facility staff have taken the following courses in Relias: Communication and People with Dementia, Cultural (6A) Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 competence, Ethical Considerations and The Aging Process. These courses emphasize the importance of communication. During an interview with administrator (S#1) he stated that the facility staff is able to communicate with the residents. Also, (S#1) stated that the facility staff does not have problems understanding the residents in care. During interviews with residents (R#1-R#6) (5) out of (6) stated that they are able to communicate with the facility staff and they do not have problems understanding what the facility staff says to them. During an interview with facility staff (S#2-S#8) seven (7) out of seven (7) stated that they are able to communicate with the residents in care and some of the ways they used are: reviewing resident’s records, taking their time to make sure residents understand them. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Assistant Executive Director/Memory Care Director, Cecille Bernabe, and Office Business Director, Raul Periera, and a copy of this report was provided. (7A)

On 08/02/24, Licensing Program Analysts (LPA), Wendy Gibbs, Deborah Lee, and Yolanda Rosser, conducted an unannounced visit to the facility listed above. LPA’s met with Assistant Executive Director, Cecille Bernabe, and Business Office Manager Raul Pereira, and the purpose of today’s visit was explained. The facility is licensed to serve (137) non-ambulatory elderly adults ages 60 and above, which (13) may be bedridden. Delayed egress approved for memory care and transitional units. Physical Plant/Structure The facility consists of two buildings, one building is designated for Assisted Living and Memory Care residents and consists of two (2) floors and the other building consists of Memory Care residents and has three (3) floors. There is a total of (54) Assisted Living units and (55) Memory Care units’ rooms, kitchen, dining rooms, theater room, multipurpose room, bistro areas, business office, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room and four (4) outside shaded patio with table and sufficient chairs and putting green. LPAs did not observe any bodies of water on the premises. LPAs observed all walkways and passages around the facility to be clean, clear, and free of obstructions, debris, and hazards. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident Rooms During the facility tour, LPAs inspected twelve (12) resident apartments and observed them to be clean and in good repair. The resident apartments inspected were 102, 106, 206, 219, 214, 216, 224, 232, 117, 104(M), 210(M), and 308(M). Resident’s apartments are furnished with their personal furniture. LPAs observed all apartments have the required furniture including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. LPAs observed beds to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Linens are supplied by the resident, but the facility does have a storage room with linens, and blankets incase a resident needs an additional supply. The water temperature in resident rooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPAs observed the facility to be appropriately furnished during time of visit. LPAs observed the game room to have ample tables, chairs, and a couch to accommodate residents. LPAs observed an ample supply of games, puzzles, and reading material, additionally the room had a television and a computer available for resident use. LPAs observed the multipurpose/activity room to have tables and ample chairs. LPAs observed an ample supply of arts and craft supplies available for resident use. The activity schedule was posted outside the door. The dining room had multiple tables and chairs to accommodate residents. LPA’s observed snacks, and drinks available for residents in the bistro area. The facility was maintained at a comfortable temperature. All rooms and hallways were observed with ample lighting. LPAs observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. Kitche n LPAs inspected the facility’s industrial kitchen and found it to be clean and sanitary. LPAs observed all appliance to be in good working repair. LPAs observed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 an ample supply of cookware, dishware, and cutleries in good repair. LPAs observed a 3-day supply of perishable and a 7-day supply of nonperishable foods properly labeled, dated, and stored. LPAs reviewed the temperature logs for the freezer and the refrigerator. LPAs observed the monthly menus posted in the dining room and at the entrance of the dining room. LPAs observed all cleaning supplies secured in a locked storage room and are inaccessible to residents. Safety LPAs observed multiple fully charged fire extinguishers last serviced on 09/12/23. The last annual fire inspection was conducted on 10/10/23. LPAs observed smoke detectors and carbon monoxide detectors to be operational. LPAs received and reviewed a copy of a current Emergency and Disaster Plan (LIC610E). The last Emergency Drill was conducted on 06/16/24. The facility does have a working landline telephone. LPAs observed all required posting throughout the facility. LPAs reviewed the maintenance logs for the two (2) generators. Staff started and ran the generators. Medications LPAs observed Centrally Stored Medications secured in a locked medication cart in the locked medical room. LPAs observed all medications to be in their original container. LPAs reviewed the medications and Medication Administration Record (MAR) for ten (10) residents. Ten out of ten resident’s MARs and medications are consistent with properly documented records. Files LPAs reviewed 12 resident files and found they contained the required documents. LPAs reviewed the Administrator and eight (8) staff files and found they contain the required documents, certification, and training. LPAs received and reviewed a copy of the facility’s Liability Insurance. During file review, LPAs observed the licensing fees are current. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Infection Control LPAs observed multiple hand sanitizing stations throughout the facility. LPAs observed an ample supply of hand soap and paper towels. LPAs observed required infection control signs posted throughout the facility. LPAs observed a 60-day supply of Personal Protective Equipment (PPE). During today's visit, LPAs did not observe or cite any deficiencies. An exit interview was conducted with Business Office Manager, Raul Periera, and Assistant Executive Director, Cecile Bernabe, and a copy of this report was provided.

Allegation: The facility HVAC is in disrepair The allegation alleges that the facility has had a broken air conditioning and heating system for about two (2) years. During the facility tour, LPA used a thermometer to measure the temperature in common rooms and resident rooms. In common rooms, in both buildings, LPA observed the thermostats were set between 72-degrees and 78-degrees Fahrenheit, and the temperatures measured 74.3-degrees in the game room, 74.8-degrees in the facility entry, 73.2-degrees in the activity room, 76.7-degrees in the dining room, 77.3-degrees in the lounge area, 75.3-degree in the 1 st floor activity room, 70.6-degrees in the 2 nd floor multipurpose room, and 74.0-degrees in the 3rd floor multipurpose room. In the resident rooms inspected, LPA observed each room had their own thermostat for residents to control the temperature in their rooms and to set it at the temperature of their choice. The following rooms were inspected, temperatures recorded, and thermostats checked, room 104 measured 74.4-degrees and thermostat set at 74-degrees, room 107 measured 71.9-degrees and thermostat set at 72-degrees, room 112 measured 74.3-degrees and thermostat set at 75-degrees, room 117 measured 71.4-degrees and thermostat set at 72-degrees, room 124 measured 76.6-degrees and thermostat set at 76-degrees, room 203 measured 77.5- degrees and thermostat set at 78-degrees, room 205 measured 75.3 and thermostat set at 74-degrees, room 212 measured 72.2-degrees and thermostat set at 72-degrees, room 221 measured 77-degrees and the thermostat set at 76-degrees, room 224 measured 74.3-degrees and Continued on LIC-9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 thermostat set at 74-degrees, room 229 measured 74.3-degrees and thermostat set at 73-degrees, and room 235 measured 78.6 and thermostat set at 77-degrees. During record review, LPA received and reviewed an invoice from Providence Consulting & Design, LLC for air conditioning maintenance, dated on 05/13/24. Additionally, LPA received and reviewed the facility’s Work Orders from 05/01/24 to present and observed there were twenty-one (21) work orders regarding the air conditioning, and 10 of the work orders were a request to adjust the thermostat for the room being either hot or cold. During an interview with S3 and S4 stated that some of the residents do not know how to adjust the thermostat and have complained in the past about it either being too hot or too cold or the thermostat not working. During interviews with Staff S1-S8, were asked if the air conditioning works in both buildings, eight (8) out of eight (8) stated the air conditioning works in all rooms. During interviews with S3 and S4, stated maintenance was conducted on the HVAC system on 05/13/24, and some of the rooms AC did not work during the maintenance but residents were provided with a portable air conditioner and fans. Additionally, S3 and S4 stated the main air conditioning units were replaced almost 2 years ago. During interviews with Staff S6-S8, stated the HVAC system is serviced twice a year, right before summer and right before winter. LPA asked Staff S2-S8 if they have received any complaints regarding the air conditioning, seven (7) out of seven (7), stated there have been complaints of resident rooms either being too hot or too cold and when the room is checked there are many instances that the resident has had difficulties operating the thermostat. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During interviews with Residents R1-R10, were asked if there have been any issues with their air conditioning in their rooms, eight (8) out of ten (10) stated there have been no issues with their air conditioning. Resident R1 stated their thermostat is broken and doesn’t work. LPA went to the resident’s room and tested the thermostat which worked properly and was set at 73, and the room temperature measured 71.6-degrees F. R9 stated the AC unit can use some work because it gets too cold, and their medication makes them cold, so it is really cold. Additionally, during interviews with Residents R1-R10, were asked if the common rooms were kept at a comfortable temperature, ten (10) out of ten (10) stated common rooms are kept at a comfortable temperature. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Assistant Executive Director, Cecille Bernabe, and Business Office Director, Raul Pereira and a copy of this report was provided.

Allegation: Facility staff do not store cleaning chemicals locked and inaccessible to resident in care. It is alleged that in the memory care unit, cleaning products are left out on the counter or put in cabinet that is not secured and is accessible to residents. During the facility tour, LPA and the Executive Director toured the full Memory Care Unit. LPA observed that on all three floors of the Memory Care Building, each kitchenette had a locked cabinet under the sink where cleaning supplies are stored. LPA observed that all cleaning products were inaccessible to residents. Staff opened cabinet and LPA observed the only cabinet with cleaning supplies in it was the locked cabinet under the sink. Additionally, LPA checked the laundry room on each floor, and observed they were secured and locked. LPA observed housekeeping cleaning rooms on the first floor of the Memory Care and observed the cleaning chemical supplies box was locked at all times. LPA observed when the housekeeper needed a different product, they unlocked the box, put away what they had, took out what they needed, and locked the box again. During interviews with staff (S1-S7), were asked if they have received training's regarding the storage of cleaning chemicals, seven (7) out of seven (7) stated they have received training through Relias and In-Services regarding the storage of cleaning chemical. Additionally, seven (7) out of seven (7) stated that when not in use cleaning products are secured in a locked cabinet under the sink and are inaccessible to residents. During interviews with Residents (R1-R8), were asked if they have observed cleaning chemicals left out on the counter at any time, Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 eight (8) out of eight (8) stated they have not seen any cleaning supplies left out and accessible. During record review, LPA reviewed training logs for seven (7) staff, LPA observed seven (7) out of seven (7) had completed the Relias training regarding Chemical Safety. Additionally, LPA received and reviewed In-Service training logs, conducted on November 18, 2023 and March 7, 2024, regarding Chemical Safety and Maintenance of Supplies/Chemicals. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated . During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

Currently there are 118 residents; of which, five (5) are non-ambulatory and sixteen (16) are receiving hospice care. LPA requested the following pertinent documents pertaining to the investigation: resident roster, staff roster, admission/memory care agreement (dated 08/04/22), power of attorney (effective 06/01/21), appraisal needs and services plan (08/04/22), physician report (08/02/22), level of care plan (dated 08/04/22), progress notes (from 08/18/22 – 08/26/22), private care agreement (dated 08/04/22), facility staff schedules (from 08/01/22 – 08/23/22), and incident report (dated 08/22/22). Due to the nature of the complaint, it was referred to the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD), Investigation Bureau (IB). Investigation Bureau (IB) accepted and assigned the full investigation to Investigator Heidy Bendana. The investigation included a review of medical records from Torrance Memorial Medical Center (dated 08/22/22); interviews with facility staff (A1, S1 – S3), residents (R1, R3, and R4), and witness (W1). IB Investigator Bendana did not interview Resident #2 (due to cognitive impairment) or Witness #2 (due to unavailability). The investigation revealed the following: Regarding Allegation #1 : this investigation revealed based on Torrance Memorial Medical Center’s medical records that Resident #1 did not sustain a fracture resulting from an unwitnessed fall at the facility on 08/22/22 nor did the medical records for admission (dated 08/22/22) mention bruising or skin tears. A CT scan was conducted of the left hip with findings showing no acute fracture was identified. No definite fracture of the left femur was identified. CT was obtained to rule out acute fracture and all findings are consistent with an old injury. Prior to being admitted to the facility, Resident #1 went for a walk in their neighborhood and was found on the ground and transported to Torrance Memorial Medical Center ER for an unwitnessed fall on 07/17/22. Resident #1 complained of some left hip pain even though clinically suspicion of fracture/dislocation was low. X-ray of the left hip did not show acute abnormality. Resident #1 was discharged to Del Amo skilled-nursing facility on 07/19/22. On 08/10/22, Resident #1 was presented to the emergency department (ER) at Torrance Memorial Medical Center for evaluation of skin tears to the upper extremities after an unwitnessed fall from their bed at the skilled nursing facility. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident #1 accidentally slipped while getting out of bed and sustained skin tears to their upper extremities. Resident #1’s responsible person disclosed that Resident #1 has “sensitive” and “thin” skin which causes bruising and skin tears to occur easily with a longer healing period. Based on this investigation, Resident #1 was admitted to Clearwater at South Bay on 08/04/22, facility staff took preventative actions because of the unwitnessed fall incident on 08/22/22. Facility staff changed Resident #1’s bed, ordered an alarm that attached to the resident’s clothing to sound off when the resident got up, a sensor mat to alert caregivers when the resident gets up from their bed, caregiver rounds were more frequent at an hour time frame, and established a toileting routine which the resident is taken to the bathroom every two (2) hours. In addition, facility staff recommended and assisted in Resident #1 having a private caregiver (Witness #2) at night 02/07/24 (between 2100 hours to 0700 hours, seven days a week). During the day, Resident #1 is in the common area where the resident is under constant supervision. Based on the evidence gathered, interviews conducted, and medical records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of Neglect/Lack of Supervision resulted in severe injury is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Lifestyle Director Kathryn O'Brien.

On 06/30/2023 LPA Randle interviewed (S1) and resident (R1). LPA requested, received, and reviewed the following information: file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. On 06/30/2023, LPA interviewed Camille Bughaw LVN and Resident (R1). LPA requested and reviewed pertinent documents pertaining to the investigation. LPA received the following pertinent documents pertaining to the investigation: Resident Roster, Staff Roster, Admissions Agreement, Needs and Services Plan, LPA reviewed Staff schedule. LPA interviewed staff (S1-S10) and residents (R1-R6). regarding allegation listed above. The investigation revealed the following: Allegation : Staff not providing a safe environment for resident(s) in care. On June 30, 2023, LPA interviewed Camille Bughaw LVN Memory Support Director. (S1). LPA asked S1 if S1 was aware of the Staff not providing a safe environment for resident(s) in care. S1 stated that S1 was aware of the incident and denied the allegation. S1 stated that resident R1 did indeed complain about a resident speaking too loud to her and she did feel unsafe at the time. S1 stated to LPA that S1 investigated the incident and found R1 had a verbal altercation with another resident regarding seating in the dining area and this was a single episode no other issues have occurred between the residents. LPA interviewed staff S2 and S2 confirmed that R1 had a verbal altercation with another resident regarding seating in the dining area where voices were raised, this was a single episode, and the issue was resolved. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued LPA interviewed R1, R1 admitted R1 had a verbal altercation with another resident regarding seating in the dining area where voices were raised, this was a single episode, R1 stated that R1 has not had any issues after the episode, however R1 stated “I did feel unsafe at the time”. LPA asked R1 does she feel safe living in the facility? R1 replied “yes I feel safe”. LPA interviewed staff (S2-S10) and staff denied the allegation Staff not providing a safe environment for resident(s) in care and provided no reported incidents from any source of residents feeling unsafe. LPA interviewed residents (R2-R6) regarding allegation listed above - Staff not providing a safe environment for resident(s) in care. The residents interviewed denied the allegation and reported they had not experienced any issues of feeling unsafe or staff not providing a safe environment. Findings Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation 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 allegation is Unsubstantiated . An exit interview was conducted and a copy of the LIC 9099 was provided to Camille Bughaw LVN. Memory Support Director