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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 02/08/2024
Date Signed: 02/08/2024 10:24:20 AM


Document Has Been Signed on 02/08/2024 10:24 AM - 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: 131DATE:
02/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Health Care Services Director, Cara DeiroTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on a death report received by Community Care Licensing on 1/31/2024. LPA met with Executive Director (ED) Laura Kephart and Health Care Services Director (HCSD) Cara Deiro and explained the reason for the visit.

Death report indicated that on 1/19/2024 at about 3:00 p.m., Resident 1 (R1) was found unresponsive sitting on the toilet by a friend who came to visit. Per death report, 911 was called, however vitals had ceased. The Sheriff's Department responded and it was determined R1 died from natural causes.

During today’s visit, LPA spoke with ED and HCSD regarding the events leading up to R1’s death. Per both staff, R1 was declared deceased by responding paramedics and cause of death was determined by Coroner. LPA was provided with Sheriff-Coroner information and case number.

R1 was part of the facility’s independent living, and it is unknown how long R1 had been sitting prior to being found. Per ED and HCSD, routine checks are not conducted on independent living residents, however, they do have a pendant they can use to alert staff for assistance. Both staff stated there had not been any medical changes and R1 was not observed to be in distress at any point prior to passing.

During today’s visit, LPA reviewed R1’s Physician Report (LIC602) dated 7/13/23. Per LIC602, R1’s primary diagnosis was emphysema and R1 was on oxygen. Per same LIC602, R1 was independent with activities of daily living and able to leave the facility unassisted.

Based on today’s observations, no further action is required at this time and no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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