Clearwater at North Tustin

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that Staff #3 (S3) did not complete the required twenty hours of annual training, and only had twelve hours of annual training documented for the year of 2024.

Maintenance and Operation-Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degrees F. This requirement was not met as evidenced by: On 8/31/22 hot water temperatures were measured in random resident rooms and the laundry room. Out of 9 rooms, 6 rooms did not have hot water that met regulation guidelines. This poses an immediate health and safety risk to residents in care.

Maintenance and Operation- Facilities which have washing machines shall:Have adequate supplies available and equipment maintained in good repair.This requirement was not met as evidenced by: End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22 and interviews were conducted with random staff. Laundry services were not completed due to no hot water.This poses an immediate health and safety risk to residents in care.

Basic Services-Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.This requirement not met as evidenced by: End of shift reports, completed by staff, were reviewed for the week of 8/24/22-8/27/22. Reports disclosed that Resident #1, #2, #3 ,#4, #5 and #6 did not receive their showers as there was no warm or hot water. This poses an immediate health and safety risk/ personal rights risk to residents in care

Basic Services-Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code. Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident's physical health, mental health, safety, or welfare would be endangered.This requirement was not met as evidenced by: On 8/18/22 R1 climbed over the side gate (eloped) and staff were not aware. R1 cannot leave the facility unassisted. This poses an immediate health and safety risk to residents.

Care of Person's With Dementia-Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.This requirement was not met as evidenced by: On 8/4/22 R1 eloped from the Community via the delayed egress doors in the Memory Care Unit(Clearbrook). Staff were unaware that R1 had left the Community. This was not the first elopement through the doors by R1. R1 also eloped on 3/27/22 and 7/24/22.

General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidenced by: based on observation and interviews the licensee did not employ sufficient food service personnel which poses a potential risk to the health and safety of residents in care.

Care of Person's With Dementia-Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.This requirement was not met as evidenced by: R1 and R2 wandered from the Community without staff supervision. According to records reviewed they cannot leave the facility unassisted and have wandering behaviors.This poses an immediate health and safety risk to residents in care.