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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001485
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:55:36 AM


Document Has Been Signed on 05/26/2022 11:55 AM - 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: 149DATE:
05/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Laura KephartTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an Incident report dated 05/13/2022. LPA met with Executive Director (ED) Laura Kephart and explained the reason for the visit.

Incident report dated 05/13/2022 indicated Resident 1 (R1) had been sent out for an evaluation after exhibiting behaviors and confusion. R1's physician requested an assessment with the Psychiatric Assessment Team (PAT) due to resident behaviors. R1 was sent out and returned with no changes. Physician to refer for a neurology consult. Per physician report dated 04/22/2022, R1 is diagnosed with Mild Cognitive Impairment and depression. R1 is new to the facility with an admission date of 04/29/2022.

During the visit, LPA spoke with R1. R1 states having difficulty adapting to the new living arrangements but indicated feeling safe at the facility.





No deficiencies noted during today's visit. 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: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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