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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 04/26/2022
Date Signed: 04/26/2022 03:18:30 PM


Document Has Been Signed on 04/26/2022 03:18 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: 145DATE:
04/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Laura Kephart and Cara DeiroTIME COMPLETED:
03:40 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 04/15/2022. LPA met with Executive Director (ED) Laura Kephart and explained the reason for the visit.

Incident report dated 04/15/2022 indicated that Resident 1 (R1) was observed to have scissors under the resident's back by caregiver. Resident is restless and agitated with caregiver by the resident's side for most of the day. R1 had been showing suicidal ideations and 911 called for evaluation. R1's family declined to have the resident sent out for a psychiatric evaluation. Paramedics declined to transport as well pending a direct threat of suicide. Facility requested a 24 hour care companion while plan for memory care was put in place. Family subsequently took the resident later that day to emergency room. Resident returned the next day with medication adjustment. Memory Care Director assessed the resident on 04/16/2022 for appropriateness in memory care. R1's family was advised resident must stay with a care companion until 04/18/2022 while the resident stabilized. Family decided to move resident to a board and care and moved out on 04/21/2022.
Per physician report dated 07/21/2021, R1 is diagnosed with Mild Cognitive Impairment with possible wandering behaviors. Physician report indicates mild confusion.


Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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