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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:42:26 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
04/02/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210402162101
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:
04/15/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Laura KephartTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility refused to take resident back from Skilled Nursing Facility
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 care plan and physician report. Regarding the allegation that facility refused to take resident back from Skilled Nursing Facility, the investigation revealed the following: On 03/27/2021, Resident 1 (R1) was transferred to Mission Hospital after four falls in three days. R1 was evaluated at Mission Hospital and subsequently transferred to a skilled nursing facility (SNF) for rehabilitation. Prior to the last fall, R1 was re-assessed by facility nurse on 03/25/2021 and R1's family notified of increased level of care. Family was notified that a care companion would be needed upon return from the hospital due to increased falls. Facility states ongoing conversations with family regarding the need for increased care and/or admittance into memory care unit. All parties involved confirm the SNF has not contacted the facility for resident discharge 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: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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-20210402162101
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: 04/15/2021
NARRATIVE
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nor was R1's family told the resident could not return. Therefore, the allegation is 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 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