306001485-2-18-2021-22-AS-AORZ-BZENXH-20210324105106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 02/18/2021
Date Signed: 02/18/2021 11:37:35 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
12/24/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201224161006

FACILITY NAME:	SAN CLEMENTE VILLAS BY THE SEA		FACILITY NUMBER:	306001485
ADMINISTRATOR:	LAURA KEPHART		FACILITY TYPE:	740
ADDRESS:	660 CAMINO DE LOS MARES		TELEPHONE:	(949) 489-3400
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	190	CENSUS: 116	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Laura Kephart		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Residents needs is not being met
Resident is being denied visitors

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Laura Kephart and explained the reason for the visit.
During the course of the investigation, LPA toured Resident 1's (R1) room, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report, resident assessment, and visitor sign in sheets. Regarding the allegations that resident needs are not being met and resident is being denied visitors, the investigation revealed the following: R1 is currently on hospice care and being seen by hospice personnel. Hospice documentation indicates resident was being bathed by a bath aide. Facility states supplementing with a bath as needed. LPA observed R1 appeared to be clean and well taken care of upon observation on two different occasions. R1's responsible party indicates no challenges or issues with R1's hygiene. R1's responsible party indicates no challenges to visiting once the resident was admitted to hospice care. Prior to that admittance, family was visiting outside. Facility provided sign in sheets indicating R1 was receiving visitors. CONTINUED ON LIC 9099C DATED 02/18/2021

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201224161006

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: 02/18/2021

NARRATIVE

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Per responsible party, an out of state visitor arrived around Christmas to visit R1. Visitor did not quarantine after arriving on a plane, complete the health assessment or wear proper PPE. However, the visitor did visit with the resident outside of public health guidelines. Public health guidelines indicated inside visitation would be allowed after the facility had no new transmissions of Covid-19 for 14 days and furthermore indicating that visitors should not enter the facility. Facility was in Covid-19 surge at time of visit. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

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