306001485-6-26-2023-22-AS-AORZ-CT9UEV-20230629153145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 06/26/2023
Date Signed: 06/26/2023 03:04:55 PM

Unsubstantiated

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
04/10/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230410142343

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: 136	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Laura Kephart		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not respond to resident's calls in a timely manner resulting in hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation 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 witnesses as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegation that staff did not respond to resident's calls in a timely manner resulting in hospitalization, the investigation revealed the following: On 02/21/2023, Resident 1 (R1) pushed the resident's pendant. Staff 1 (S1) responded to the resident's room but did not see resident in the room. S1 went to the resident's usual locations in the facility to locate the resident but was unsuccessful. In the meantime, Director of Clinical Services (DCC) and Nurse Practitioner (NP) were walking down the hallway when they smelled burning rubber. DCC attempted to make contact with R1 CONTINUED ON LIC 9099C DATED 06/26/2023

Unsubstantiated

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: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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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Control Number 22-AS-20230410142343

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: 06/26/2023

NARRATIVE

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who did not answer the door. DCC and NP made entry into the resident's room and observed the resident in the restroom halfway off the motorized scooter against the wall. The wheels on the scooter were still turning causing a burning smell. R1 was slow to respond and pale. NP assessed resident's vitals which were appropriate. Resident was sent out via 911 for further assessment. R1 and witnesses interviewed confirmed R1 had become dizzy and nauseous. R1 went to the restroom and passed out while in the resident's motorized scooter. R1 and family confirm a new diagnosis of Atrial Fibrillation (A-Fib) at the hospital after the incident. A-Fib is thought to be the cause of the resident becoming dizzy and passing out. Resident had no residual injuries due to the incident in the restroom. While there was a delay in reaching the resident, facility staff had responded but unfortunately did not check the resident's restroom. 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 and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

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