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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:05:57 PM


Document Has Been Signed on 12/22/2022 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 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: 138DATE:
12/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Cara DeiroTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a case management visit to follow up on incident reports received by Community Care Licensing on 12/02/2022 and 12/19/2022. LPA was greeted and granted entry into the facility by Director of Healthcare Services Cara Deiro and explained the reason for the visit.
Incident report dated 12/02/2022 indicated Resident 1(R1) had returned from a family visit in Arizona where the resident had sustained a fall. Upon return from the family visit, resident was discovered by staff on the floor after sliding out of the resident's recliner. Resident was sent out to the hospital to be assessed. R1 had no injuries but was diagnosed with Influenza. Facility is now providing assistance with showering and dressing. Resident is able to ambulate to the dining room for meals. Per physician report dated 07/27/2021, R1 is diagnosed with Mild Cognitive Impairment and is ambulatory. Resident is able to manage own medications. LPA attempted to speak with R1 but the resident is out of the facility for the holidays.

Incident report dated 12/19/2022 indicated R2 was observed by staff at the grocery store adjacent to the facility. Resident was redirected back to the facility by staff. The following day, R2 was observed leaving the community to go to the store again. Staff were unable to redirect the resident back into the facility and 911 was called. Sheriff responded and stated they would not return the resident to the facility as the resident was alert, oriented and had personal rights. Facility called resident's daughter who came to the facility and escorted the resident back. Physician report dated 10/02/2022 indicated R2 is diagnosed with Mild Cognitive Impairment and is unable to leave the facility unassisted. Facility obtained a change in orders dated 12/21/2022 from R2's physician indicated resident is now able to leave the facility unassisted. The reason for the change is due to improvement in the resident's clinical status. Resident had resided in a skilled for clinical reasons prior to living at the facility. LPA met with R2 during the visit. R2 appeared clean and well taken care of.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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