306001485-4-13-2023-22-AS-AORZ-CR3TNW-20230420145325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:25:59 AM

Unfounded

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
04/18/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220418142649

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: 133	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Laura Kephart		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility failed to address scabies outbreak

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 Executive Director Laura Kephart and explained the reason for the visit. Director of Clinical Services Cara Deiro was present as well.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and medication orders. Regarding the allegation that facility failed to address scabies outbreak, the investigation revealed the following: R1 was observed to be itchy by facility staff and contacted physician by fax on 04/03/2022 to address the itching. On 04/07/2023, R1's family member took the resident to see physician in person and was prescribed topical ointments to treat scabies and itching. Resident was seen by home health the month prior for itchy skin and has a history of itchy skin as a possible side effect of insulin products. Facility denies any outbreak of scabies in the facility and none were reported to licensing. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to facility representative.

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: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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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