198320602-8-27-2026-11-AS-PMAA-DXRTK9-20260909144735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320602
Report Date: 08/27/2026
Date Signed: 08/27/2026 02:31:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2026 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20260821103410

FACILITY NAME:	LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE		FACILITY NUMBER:	198320602
ADMINISTRATOR:	FLAHERTY, TRACY		FACILITY TYPE:	740
ADDRESS:	8070 BEVERLY BLVD		TELEPHONE:	(213) 808-0170
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	124	CENSUS: 46	DATE:	08/27/2026
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Executive Director Trucy Flaherty		TIME COMPLETED:	02:42 PM

ALLEGATION(S):

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Staff pushed resident resulting in injury.
Staff did not ensure resident received medical treatment in a timely manner.

INVESTIGATION FINDINGS:

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On 08/27/26 at 10:30 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Trucy Flaherty (Staff #1/S1) as the purpose of today’s visit was explained.

The investigation consisted of the following: On 08/27/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Residents #1-2 (R1-R2): Emergency ID forms, pre-appraisals, Physicians reports, needs and service plans, medication list, and copies of any incident reports and facility notes. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with Residents# 1-5 (R1-R5), and from 12:30pm- 1:40pm interviews were conducted with staff #1-5 (S1-S5). LPA conducted a review of R1's files, and facility notes.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260821103410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE	FACILITY NUMBER: 198320602
	VISIT DATE: 08/27/2026

NARRATIVE

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In the investigation revealed the following:
Allegation: Staff pushed resident resulting in injury.
It is alleged that a staff members pushed down a resident in care which resulted in shoulder pain. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with R1-R5 regarding the allegation above. 4 of the 5 residents interviewed denied the allegation above and report feeling safe and having no concerns about their safety. 1 of the 5 residents interviewed confirmed the allegation above and stated that a former employee caused resident to fall off their bed and hurt their shoulder. On 08/27/25 from 12:30pm- 1:40pm interviews were conducted with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above and stated that there has not been any terminations within the last 2 months. LPA conducted a review of R1's file, and facility notes dated: 05/04/26- 08/24/26. Per facility note dated: 07/16/26 R1 has been complaining of shoulder pain, per POA there is no history of recent falls, and resident has had this issue chronically, physician was notified for request of pain medication. Note dated: 08/24/26 staff reached out to the R1's physician regarding continuous shoulder pain as Tylenol is not providing adequate relief. LPA reviewed service plan dated: 06/23/26: Full assistance with toileting, transfers and mobility as R1 has a history of falls.
LPA conducted a file review and did not observe any incident reports related to the allegation above.

Allegation: Staff did not ensure resident received medical treatment in a timely manner.
It is alleged that resident in care requested to see a Doctor after obtaining an injury and staff did not assist. On 08/27/26 from 11:00 am- 12: 30pm LPA conducted Interviews with R1-R5 regarding the allegation above. 2 of the 5 residents interviewed denied the allegation above, 2 of the 5 residents interviewed did not have any knowledge of the allegation as they stated they have not had the need for medical attention, but believe the staff would assist. 1 of the 5 residents interviewed confirmed the allegation above and reported that resident is still waiting to see a Doctor. On 08/27/25 from 12:30pm- 1:40pm interviews were conducted with S1-S5 regarding the allegation above. 5 of 5 staff interviewed denied the allegation above, and stated that staff has not refused to seek medical attention for residents in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026

LIC9099 (FAS) - (06/04)

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