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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 10/10/2022
Date Signed: 10/10/2022 03:17:41 PM


Document Has Been Signed on 10/10/2022 03:17 PM - 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: 148DATE:
10/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Cara DeiroTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a case management visit to follow up on an incident report received by Community Care Licensing on 09/23/2022. LPA was greeted and granted entry into the facility by Director of Healthcare Services Cara Deiro and explained the reason for the visit.

Incident report dated 09/08/2022 indicating Resident 1 (R1) was observed outside the community on the residents golf course and was unsure how to return to the community. Two "Good Samaritans" assisted the resident by calling the community. Staff went to assist resident and 911 was called to assess resident. Resident refused transport. Investigation revealed train crossing arms were down and resident had to circumvent through an unfamiliar neighborhood to return to the community. Resident travels through the area on a golf cart frequently. Per physician report dated 06/22/2022, R1 is able to leave the facility unassisted and is fairly independent. R1 was assessed by physician to be without any adverse affects and physician remains allowing resident to leave the facility. LPA attempted to meet with resident during the visit but R1 was out of the community during the visit.





No further action required. Exit interview conducted 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: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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