Clearwater Healthcare Center: Call Light Failures - CA
Inspectors who visited the facility at 1517 East Knickerbocker Drive on May 27 found that residents were waiting longer than that.
The call light is the most basic tool a nursing home resident has. For someone who cannot get out of bed without help, or who needs to reach a bathroom before an accident, or who feels chest pain in the night, it is the one thing standing between them and whatever comes next if nobody answers. At Clearwater, that tool was not working the way it was supposed to.
The facility's own written policy, last revised in March 2018, stated that staff were responsible for monitoring call lights and making sure they were answered promptly, regardless of which staff member was assigned to which resident. The standard the policy pointed toward, according to the assistant director of nursing, was a response within two to three minutes.
The gap between two to three minutes and more than ten minutes is not a small one. It is the difference between a resident who gets help in time and one who tries to get up on their own.
Inspectors classified the harm level as minimal or potential rather than actual, and noted that few residents were affected. Those qualifications matter in regulatory terms. They matter less if you are the person in the bed, pressing the button, waiting.
The complaint inspection, triggered by a report filed against the facility, found the deficiency and documented it. The assistant director's own words became part of the record, a frank acknowledgment that the facility understood what the standard was and that the standard was not being met.
Clearwater Healthcare Center did not receive an immediate jeopardy citation, the most serious level of federal violation, for this finding. The inspection record does not describe a resident who fell while waiting, or a medical emergency that went unattended. What it describes is a system that the facility's own leadership acknowledged was failing, at least some of the time, for at least some residents.
That acknowledgment is its own kind of finding. The assistant director did not dispute what inspectors were looking at. She defined the problem, named the threshold, and confirmed it was being crossed.
Falls are one of the leading causes of injury and death among nursing home residents. They are also one of the most preventable, when staff are present and responsive. A resident who waits more than ten minutes to have a call light answered and then decides to try standing on their own, in the dark, at two in the morning, is a resident who may not make it back to bed.
The facility's policy language offered no ambiguity. Lights were to be monitored. Responses were to be prompt. The assignment of a specific aide to a specific resident was not supposed to matter; whoever was available was supposed to answer.
Whether that is what happened in practice is what inspectors were there to determine. The record they left behind suggests it was not.
Clearwater Healthcare Center has 30 days from the completion of an inspection to submit a plan of correction to state and federal regulators. That plan is not included in the inspection document. For residents who pressed a call light and waited, the plan of correction comes after the fact.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clearwater Healthcare Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 14, 2026 · Our methodology
CLEARWATER HEALTHCARE CENTER in STOCKTON, CA was cited for violations during a health inspection on May 27, 2026.
Inspectors who visited the facility at 1517 East Knickerbocker Drive on May 27 found that residents were waiting longer than that.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.