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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006014
Report Date: 07/01/2025
Date Signed: 07/01/2025 10:30:00 AM

Substantiated


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
03/03/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250303090520
FACILITY NAME:RAYA'S PARADISE OF SAN CLEMENTEFACILITY NUMBER:
306006014
ADMINISTRATOR:WESTPHALN, MONICAFACILITY TYPE:
740
ADDRESS:101 AVENIDA CALAFIATELEPHONE:
(949) 420-9898
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:80CENSUS: 30DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Monica WestphalnTIME COMPLETED:
08:20 PM
ALLEGATION(S):
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Staff served as resident’s agent under a power of attorney
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, resident and witness as well as reviewed and obtained pertinent documentation such as Durable Power of Attorney (DPOA) paperwork. Regarding the allegation that staff served as resident’s agent under a power of attorney, the investigation revealed the following: Resident 1 (R1) indicated that Facility Administrator had recommended becoming the resident's DPOA due to an upcoming surgery scheduled for the resident. Resident states declining the recommendation but eventually agreed. Resident states being very ill during the signing of the document and was surprised to subsequently see an additional person as a back-up designee and prospective conservator. The back up agent and prospective conservator was listed as Jeffrey Siegle. Resident indicates the prospective conservator was not requested by the resident and gave clear instructions that the DPOA was only for the purpose of the time of the surgery. CONTINUED ON LIC 9099C DATED 07/01/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 3
Control Number 22-AS-20250303090520
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: RAYA'S PARADISE OF SAN CLEMENTE
FACILITY NUMBER: 306006014
VISIT DATE: 07/01/2025
NARRATIVE
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LPA reviewed the document showing Facility Administrator Monica Westphaln as the healthcare power of attorney for the resident signed 02/07/2025 with a back-up designee and prospective conservator Jeffrey Siegle. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the following allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250303090520
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: RAYA'S PARADISE OF SAN CLEMENTE
FACILITY NUMBER: 306006014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/21/2025
Section Cited
CCR
87217(d)(2)
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Except as provided in approved continuing care agreements, no licensee or employee of a facility shall: accept any general or special power of attorney for any such person; This req is not being met as evidenced by:
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Licensee to read the regulation and forward a statement of understanding to LPA by POC due date.
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Based on record review and interview, Licensee failed to ensure an employee of the facility was not designated as a power of attorney for R1. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3