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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:44:27 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: 139DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Laura Kephart and Cara DeiroTIME COMPLETED:
01:47 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Executive Director Laura Kephart and explained the reason for the visit. Director of Healthcare Services Cara Deiro was present as well. Administrator Laura Kephart has an administrator certificate expiring on 04/06/2023.

At 10:30 AM, LPA toured the facility with Administrator Laura Kephart. Facility has 119 residents in assisted living and 20 residents in memory care during today's visit. Facility has a beauty salon, movie theater, activity room, and library as well as two dining rooms and an auxiliary snack area. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Assisted Living resident rooms are single and double occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer. Memory Care rooms are double occupancy. Memory Care has delayed egress doors and an enclosed outside patio for residents. Common restrooms have the required hand washing signs posted. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet and documents temperatures and potential health symptoms. Facility has covid precaution postings as well as all required department postings. LPA observed both the Assisted Living and Memory Care Wellness Center. First aid kits have all required items. Facility utilizes the electronic medical record. Facility mitigation plan has been submitted and approved. LPA observed an ample supply of emergency food and water. All stairways have an emergency evacuation chair. LPA toured the outside grounds and observed multiple shaded outside visitation areas as well as a fenced and secured pool. Residents participate in activities such as exercise, music, and outings in the community. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files are up to date including emergency information and physician reports.
LPA consulted with Director of Healthcare Services and Executive Director regarding the importance of taking resident temperatures daily and documenting. CONTINUED ON LIC 809C DATED 10/21/2021
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2021
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No deficiencies noted during today's visit. An exit interview was 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: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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