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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 08/12/2026
Date Signed: 08/12/2026 12:55:46 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
08/05/2026 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260805154446
FACILITY NAME:CLEARWATER AT SOUTH BAYFACILITY NUMBER:
198603118
ADMINISTRATOR:PAUL GOZONFACILITY TYPE:
740
ADDRESS:3210 & 3212 W SEPULVEDA BLVDTELEPHONE:
(424) 488-6340
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:137CENSUS: 101DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Diane NavarroTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not prevent resident from sustaining wounds.
Staff did not ensure resident was repositioned as needed.
Staff did not ensure resident's care plan was followed.
INVESTIGATION FINDINGS:
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On 08/12/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with Executive Director Diane Navarro.

Investigation consisted of the following: On 08/11/2026, the Department obtained Personnel Record, Register of Residents, and Residents #1 - #4 Records. LPA interviewed Staff #1 – 9 (S1 – S9) and Witness #1 (W1). On 08/12/2026, the Department obtained Resident #3’s Face Sheet. LPA interviewed Staff #10 - #11 (S10 - S11), Resident #2 - #8 (R2 – R8) and Witnesses #2 - #3 (W2 – W3). Note: Resident #1 passed away in 05/2026. Resident #3 did not respond to questions. Resident #9 - #10 were unavailable for interviews.

Investigation revealed the following:
Allegation: Staff did not prevent resident from sustaining wounds. It is alleged Resident #1 (R1) developed two bedsores seven months ago. Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
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 4
Control Number 11-AS-20260805154446
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: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 08/12/2026
NARRATIVE
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Record review revealed the following: Review of Physician’s Report (12/11/24) does not reveal a history of skin breakdown. R1 can transfer independently but for the purpose of fire clearance, R1 is nonambulatory. R1’s secondary diagnosis is dementia. Review of Needs and Services Plan (08/11/25) revealed R1 would receive support for safe ambulation, mobility and repositioning. Review of Torrance Memorial Medical Center (01/27/26) revealed R1 went to the hospital for nausea, vomiting, cancer, and weakness. Review of Hospice Initiation revealed R1 started hospice on 02/19/26. Review of Hospice Healthcare plan (ordered 03/10/26) revealed R1 had a stage 2 pressure injury to sacroccyx. A wound care specialist was ordered (03/17/26) for wound consult. Review of Outside Agency (Hospice) Documentation (03/19/26) revealed R1 was seen for wound care evaluation and treatment. Review of Outside Agency (Hospice) Documentation (04/04/26) revealed R1’s wound dressed on sacrococcyx and healing.
Review of Physician’s Report (05/19/26) revealed R1 has a history of skin breakdown (sacrococcyx unstageable) and requires continuous bed care. R1 cannot independently transfer to and from bed. R1 is bedridden. Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 did not have a pressure injury at admissions (02/19/26). R1’s skin was clear and intake. R1 was referred to a wound care specialist on 03/17/26 and the first visit was on 03/19/26. R1 would receive wound care services weekly or as needed. Upon readmission (04/24/26), R1 did not have an open wound. Witness #2 (W2), Private Caregiver, indicated Resident #8 has not developed any bed sores or wounds. Witness #3 ((W3), Power of Attorney to Resident #3, indicated R3 recently developed a wound but it is R3’s fault because R3 refuses to move. Staff #6 (S6) indicated R1 had a little skin breakdown, nothing massive, towards the end of life. S6 indicated R1 was repositioned before every change. Staff #8 (S8) does not recall R1 having a wound prior to hospice. Staff #9 (S9) indicated R1 did not have a wound but redness prior to hospice. Six out of six resident interviews (R2, R4 – R8) indicated they have not developed any wounds since living at the facility. Observations revealed the following: LPA observed R3, R5, R8 in hospital bed and R4 and R6 in wheelchairs.

Regarding the allegation, “Staff did not prevent resident from sustaining wounds,” based on record review, interviews, and observations, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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.
Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260805154446
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: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 08/12/2026
NARRATIVE
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 Allegation: Staff did not ensure resident was repositioned as needed
Record review revealed the following: Review of Needs and Services Plan (08/11/25) revealed R1 would receive support for safe ambulation, mobility and repositioning. Review of Physician’s Report (05/19/26) revealed R1 has a history of skin breakdown and requires continuous bed care.
Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 should be repositioned every two hours or as needed. Witness #2 (W2), Private Caregiver, indicated Resident #8 is repositioned every 2 – 3 hours. Witness #3 ((W3), Power of Attorney to Resident #3, indicated staff repositions R3 all of the time. Seven out of seven staff interviews (S2 - S6, S8 - S9) indicated residents are repositioned every two hours. Three resident interviews (R2, R4, R7,) indicated they do not need assistance with repositioning. Three resident interviews (R5 – R6, R8) indicated staff assists with repositioning. Observations revealed the following: LPA observed R3, R5, R8 in hospital bed and R4 and R6 in wheelchairs.

Regarding the allegation, “Staff did not ensure resident was repositioned as needed,” based on record review, interviews, and observations, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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.

Allegation: Staff did not ensure resident's care plan was followed
It is alleged Resident #1 (R1) choked while eating because staff did not monitor R1 while eating. Record review revealed the following: Review of Physician’s Report (05/19/26) revealed R1 is unable to feed self and special diet needs are thickened liquids and pureed.
Interviews revealed the following: Interview with Hospice Representative (Witness #1/W1) indicated R1 was on a pureed diet but on 04/29/26, it was changed by a family member to a mechanical soft diet. Witness #2 (W2), Private Caregiver, indicated W2 feeds Resident #8. Witness #3 ((W3), Power of Attorney to Resident #3, indicated R3 can feed self and staff ensures that food is finely chopped up. W3 indicated R3 has not had a chocking incident. Interview with Executive Director (S1) indicated R1 did not pass away from chocking but R1 was on hospice and passed away around 3:40 PM on 05/22/26. Interview with Staff #6 (S6) indicated S6 had repositioned and changed R1 prior to R1’s passing. R1 was not eating prior to passing away. Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260805154446
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: CLEARWATER AT SOUTH BAY
FACILITY NUMBER: 198603118
VISIT DATE: 08/12/2026
NARRATIVE
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S6 indicated S9 went to R1’s room to find out what R1 wanted for dinner and found R1 unresponsive. Interview with Staff #9 (S9) indicated finding R1 unresponsive in bed. S9 indicated R1 did not have any food near the time of death. S9 indicated R1 could not swallow and was not eating. Staff #10 indicated dinner is served around 4:00 PM. Three resident (R2, R4, R7) indicated they can independently feed themselves. Three resident interviews (R5 – R6, R8) indicated staff assist with feeding.

Regarding the allegation, “Staff did not ensure resident's care plan was followed,” based on record review and interviews, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. 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.

An exit interview was conducted, technical assistance provided, and a hard copy was provided to the Executive Director Diane Navarro.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4