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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 03/15/2022
Date Signed: 03/15/2022 01:29:24 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
02/09/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220209101250
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: 142DATE:
03/15/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Laura Kephart and Cara DeirosTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not meet resident's needs
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 Memory Care unit, interviewed staff and reviewed and obtained pertinent documentation such as text messages and physician report. Regarding the allegation that staff did not meet resident's needs, the investigation revealed the following: Resident 1 (R1) resides in the Memory Care unit with a diagnosis of Dementia and is incontinent. On 02/05/2022, R1 was in the common area of the memory care unit and verbalized a need to use the restroom. Per interviews conducted, Staff 1 (S1) indicated the resident would need his assigned caregiver to assist the resident and did not respond to resident. The resident then had a bowel movement in the living room of the Memory Care unit. S1 stepped in the bowel movement and got upset and started yelling. S1 was suspended and subsequently quit employment at the facility. Three out of three staff interviewed indicated incontinence care is provided at least every two hours depending on the resident's needs. CONTINUED ON LIC 9099 DATED 03/15/22.
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: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
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-20220209101250
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: 03/15/2022
NARRATIVE
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R1 no longer resides at the facility. 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: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2