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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:44:30 PM

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: DATE:
07/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Laura KephartTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an Incident report dated 06/16/2021. LPA met with Executive Director (ED) Laura Kephart and explained the reason for the visit.

Incident report dated 06/16/2021 indicated that Staff 1 (S1) hit Staff 2 (S2) in the face during training. S1 was training S2. Law enforcement was called and S1 was escorted out of the building with no charges pressed by S2. Both staff members were subsequently terminated for violation of facility policy. The incident occurred in Resident 1's room (R1). Staff 2 reported S1 was rough with the resident while training. S1 states showing S2 how to maneuver the resident when the resident is kicking. No injuries noted to resident. During the visit, LPA toured the resident's room as well as met with R1. R1 resides in memory care unit and LPA unable to complete interview with resident. R1 appeared clean and well taken care of. LPA obtained contact information for both staff members during the visit. All staff were retrained on code of conduct, violence in the workplace, and mandated reporting.



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: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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