306001485-12-14-2023-22-AS-AORZ-CYRRE2-20231222115646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:56:03 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
05/11/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210511153728

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: 135	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Laura Kephart		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff neglect resulting in resident becoming dehydrated
Staff did not recognize a change in resident's condition
Staff did not ensure resident was properly clothed
Facility not following resident's care plan
Resident was left in a soiled diaper for a long period of time
Neglect of resident resulting in pressure injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff, resident and witnesses as well as reviewed and obtained pertinent documentation such as physician report and caregiver task lists. Regarding the allegations that staff neglect resulting in resident becoming dehydrated, staff did not recognize a change in resident's condition, staff did not ensure resident was properly clothed, facility not following resident's care plan, resident was left in a soiled diaper for a long period of time and neglect of resident resulting in pressure injuries, the investigation revealed the following: Four out of four staff confirm water is available at all times for Resident 1 (R1) but resident refuses. Water is poured in a cup for resident. Facility documentation indicates reminder for resident to drink water on the caregiver task list. Resident is assessed annually and had an assessment on 09/30/2020 and 04/23/2021 as well as a physician assessment on 08/09/2020. CONT ON LIC 9099C DATED 12/14/2023

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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 4

Control Number 22-AS-20210511153728

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: 12/14/2023

NARRATIVE

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Resident has a history of diarrhea which facility has documented. Resident is not conserved nor has a power of attorney and chooses to make their own food choices which may have resulted in weight gain and a propensity for gastrointestinal issues. Resident stated that the resident is in charge of their choices and will do what the resident wants. Due to resident's rights, facility is unable to enforce a family's dietary requests for resident. LPA reviewed resident's file and resident did not have any written physician orders regarding dietary restrictions including water intake. Facility had physician orders for probiotic as well as Imodium to address the issues. Four out of four staff as well as resident confirm that resident prefers to be unclothed. Staff indicate requesting additional clothing from resident's family when clothing became too soiled for use but receiving no response or additional clothing provided. Facility documentation indicated that resident had a red rash on the buttocks, perineal area and groin in April/ May of 2020. There is no documentation of any additional redness after May 2020. Facility notified physician of rash and Mystatin cream was prescribed. There is no documentation of any pressure injury. Three out of three staff deny a lack of incontinence care on staff's part and indicate resident was noncompliant with incontinence care. Facility documentation supports the noncompliance as caregivers were noting refusal of incontinence care. Per resident's physician report dated 08/09/2020, resident is diagnosed with Mild Cognitive Impairment. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations 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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
05/11/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210511153728

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: 135	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Laura Kephart		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff failed to communicate residents needs with responsible party
Staff increased resident's rate without notice

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff, resident and witnesses as well as reviewed and obtained pertinent documentation such as facility emails and billing statements. Regarding the allegations that staff failed to communicate resident's needs with responsible party and staff increased resident's rate without notice, the investigation revealed the following. Resident 1 is self responsible without a power of attorney or conservatorship. However, facility documentation indicates facility was in communication with the resident's family member frequently. Four out of four staff as well as two out of two management confirm regular communication with resident's family. Email correspondence as well as interviews conducted indicate resident's family was advised of the rent increase and move to the requested new apartment. The move date was 08/05/2020 to a smaller apartment and LPA confirmed the apartment has the same central air conditioning as the previous apartment. Based on interviews conducted and record review, CONT ON LIC 9099C DATED 12/14/2023

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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20210511153728

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: 12/14/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4