306001485-5-26-2022-22-AS-AORZ-CF5U87-20220606152100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001485
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:57:07 AM

Unfounded

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
05/17/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220517115220

FACILITY NAME:	SAN CLEMENTE VILLAS BY THE SEA		FACILITY NUMBER:	306001485
ADMINISTRATOR:	LAURA KEPHART		FACILITY TYPE:	740
ADDRESS:	660 CAMINO DE LOS MARES		TELEPHONE:	(949) 489-3400
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	190	CENSUS: 149	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Laura Kephart		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident left in soiled linens
Resident missed transportation to Dr.appointments

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate investigation on the above allegation. LPA was greeted and granted entry by Executive Director Laura Kephart and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report and pre-appraisal. Regarding the allegations that resident missed transportation to Dr. appointments and resident left in soiled linens, the investigation revealed the following: Resident 1's (R1) care companion scheduled an eye appointment for R1 at Costco on two different occasions. Per interviews conducted, the appointments were canceled by care companion who is no longer employed with the resident. Facility provided documentation of canceled appointment and stated an appointment is pending for eye appointment to be conducted at the facility. Two out of two staff and two out of two witnesses state R1 is not left in soiled linens. Responsible party denies allegations and states satisfaction with facility staff. Therefore, the allegations are 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.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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