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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 04/08/2021
Date Signed: 04/15/2021 03:43:37 PM



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
02/11/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210211104431
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: 118DATE:
04/08/2021
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Laura KephartTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff is rough with resident(s) during bathing
Staff makes inappropriate comment(s) in front of resident(s)
Staff uses profanity in front of resident(s)
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 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 witnesses as well as reviewed and obtained pertinent documentation such as caregiver assignments and staff schedule. Regarding the allegations that staff is rough with resident(s) during bathing, Staff makes inappropriate comment(s) in front of resident(s), and Staff uses profanity in front of resident(s), the investigation revealed the following: Per facility documentation, Staff 1(S1) bathes one resident on a weekly basis. Resident 1 (R1) is bathed by S1 and states the staff is very gentle and has never been rough or used profanity. R1 states there has not been inappropriate behavior or comments and is happy to have S1 assist the resident. Four out of four staff and six out of six residents deny seeing any inappropriate behaviors or comments from any caregiver or nurse at the facility. S1 denies all allegations. Therefore the allegation is deemed unfounded meaning the allegation is false, could not have happened and/ or is CONTINUED ON LIC 9099C DATED 04/15/2021
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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 2
Control Number 22-AS-20210211104431
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: 04/08/2021
NARRATIVE
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without a reasonable basis.

Exit interview conducted with Administrator and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2