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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 11/09/2020
Date Signed: 11/10/2020 07:24:20 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2020 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20200702135458
FACILITY NAME:SAN CLEMENTE VILLAS BY THE SEAFACILITY NUMBER:
306001485
ADMINISTRATOR:LAURA KEPHARTFACILITY TYPE:
740
ADDRESS:660 CAMINO DE LOS MARESTELEPHONE:
(949) 489-3400
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:190CENSUS: 128DATE:
11/09/2020
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Laura KephartTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff failed to provide assistance to residents while in care
Staff speaks inappropriately about a resident while in care
Staff hit a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Executive Director Laura Kephart. During the course of the investigation, LPA interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility internal investigation report, staff schedule, and staff termination paperwork. Regarding the allegations that staff failed to provide assistance to residents while in care, staff speaks inappropriately about a resident while in care, and staff hit a resident while in care, the investigation revealed the following: Community Care Licensing (CCL) received an email outlining the above allegations. Facility also received said letter. Facility conducted their own investigation to which they were unable to corroborate the allegations but resulted in the termination of two caregivers for violation of facility policy. The violations were not pertaining to the allegations in this complaint. LPA interviewed seven staff and seven residents regarding the allegations. Seven out of seven staff confirm ongoing issues between staff working on the overnight shift. Seven out of seven residents interviewed denied the circumstances of the allegations. CONTINUED ON LIC 9099C DATED 11/09/2020.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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 2
Control Number 22-AS-20200702135458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAN CLEMENTE VILLAS BY THE SEA
FACILITY NUMBER: 306001485
VISIT DATE: 11/09/2020
NARRATIVE
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All residents interviewed were complimentary of facility caregivers and did not voice any areas of concern. Facility staff as well as Ombudsman confirm an ongoing dispute between caregivers on the overnight shift. The dispute has been remedied by the termination of two caregivers on the overnight shift. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
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