306001485-12-14-2023-22-AS-AORZ-CYQVZ3-20231221155206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:57:46 PM

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
05/11/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210511162320

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:	01:01 PM
MET WITH:	Laura Kephart		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility is falsely advertising food menu.
Food is not of quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Administrator Laura Kephart and explained the reason for the visit. Cara Deiro was present as well.
During the course of the investigation, LPA toured the dining room, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility menu. Regarding the allegations that facility is falsely advertising food menu and food is not of quality, the investigation revealed the following: LPA reviewed menu and observed residents dining on multiple occasions. Facility menu has varied items including steak at least once a week. Residents have multiple items to choose from and LPA observed food appeared healthy and prepared appropriately. Five out of five residents stated satisfaction with the food choices and indicated meeting with the chef to express food suggestions. Facility phone recording indicates advertising high end foods for special occasions only. 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.

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)

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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-20210511162320

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:	01:01 PM
MET WITH:	Laura Kephart		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings
Facility has pests
Staff did not properly dispose of trash
Resident's room is unsanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Administrator Laura Kephart and explained the reason for the visit. Cara Deiro was present as well.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as end of shift reports. Regarding the allegations that staff did not safeguard resident's personal belongings, facility has pests, staff did not properly dispose of trash and resident's room is unsanitary, the investigation revealed the following: Four out of four staff indicate cleaning and disposing of Resident 1's (R1) trash as well as feeding and cleaning up after the resident's cat. R1 confirms staff cleaning and assisting with the cat. Staff deny trash being left on the floor. Facility documentation indicates cleaning and pet assistance was being provided to resident. Resident's family requested the cat be fed a half can of food however resident facilitated a whole can for feeding thus resulting in the need for more cans of cat food. All staff deny stealing cat food or anything else. CONTINUED 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: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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-20210511162320

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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Staff are not sure of the status of a chair missing during the move to another apartment. Facility indicates inquiring about the chair per family request with the third party moving agency and receiving no information. Resident denies any missing items during the move or at any time. LPA observed the theft and loss record and there is no documentation of any theft regarding the resident. Administrator denies knowledge of any theft. Facility indicates examining resident's room for pests and no evidence was observed. However, due to family request, the resident's room was exterminated on 04/23/2021. Facility staff indicate due to resident's resistance to assistance with activities of daily living, resident's room and clothing were frequently soiled requiring replacement items which were not consistently provided by family. Facility staff are unsure about missing pillows, towels or broken ceramic pieces and state if there was an issue it would have been brought to their attention and been addressed. R1 denies missing items. Due to conflicting information, 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 to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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