complaint·January 7, 2026

During the course of the interviews with staff, Staff 3 (S3) reported that R1 is repositioned every two hours and stated that R1 favored positioning back to his right side. Per S4, R1 did not develop a pressure injury due to staff neglect. S5 stated that R1 did not develop pressure injuries due to lack of care or staff neglect. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with AD Kornmann, and a copy of this report was provided to the facility. Per W1, he always sees staff working hard. Regarding the allegation that staff did not allowed resident access to telephone, the following was revealed: During the investigation LPA reviewed documents including the Clearwater at North Tustin Admission Agreement dated October 28, 2022, for R1. Per Admission Agreement, under Statement of Residents' Personal Rights it states residents to have reasonable access to telephones, to both make and receive confidential calls. During the course of the interviews with residents, R1 reported that he can use the telephone at anytime. During the course of the interviews with staff, S1 through S5 reported that staff always pass the telephone calls to the residents and/or stated that the residents always have access to the telephone. Regarding the statement that facility is understaffed, LPA reviewed documents including the Clearwater at North Tustin staff schedule dated May 2024. Per staff schedule, on average there are four Caregivers and one Medication Technician (MT) for the morning and evening shifts and two Caregivers and one MT for the night shift for 32 residents in care. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. LPA Ramirez conducted an exit interview and a copy of this report was provided to the facility. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with AD Kornmann, and a copy of this report was provided to the facility.