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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006014
Report Date: 07/01/2025
Date Signed: 09/18/2025 02:27:42 PM

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
02/28/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250228162254
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:
08:21 AM
MET WITH:Monica WestphalnTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Resident is being blocked from speaking with family via telephone
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to deliver findings on the above allegation. LPAs were 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 and witnesses as well as reviewed and obtained pertinent documentation such as text messages. Regarding the allegation that resident is being blocked from speaking with family via telephone, the investigation revealed the following: Four out of six witnesses state Resident 1's (R1) phone had been removed by facility staff. Facility Administrator confirms removing the phone one time for a confirmation code to get electricity turned back on at the resident’s house. Upon review of R1’s admission agreement and facility program plan, the facility does not offer services to monitor/assist in resident home bills or monitoring of resident’s funds. LPA reviewed and obtained two text messages where Staff 1 and 2 had requested another staff to remove R1's phone from the resident per Facility Administrators on 01/08/2025 and 01/21/2025. During LPA Lyman’s initial visit on March 04, 2025, 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 5
Control Number 22-AS-20250228162254
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 R1's phone and observed that a family member's phone number had been blocked. R1 denied blocking the number and did not know the process to block a number on the phone. While it remains unclear which staff member blocked the family member on the resident’s personal cell phone, the facility’s removal of R1’s personal cell phone out of their possession was determined to be unnecessary for the purposes of obtaining a code, as it could have been gathered while remaining in the possession of the resident. The removal of R1’s personal cell phone violated their personal rights to make and receive confidential calls and based on preponderance of evidence was blocked by one of the facility staff. 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.

*This is an amended report.
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 5
Control Number 22-AS-20250228162254
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)
Deficiency Dismissed
Type A
07/02/2025
Section Cited
CCR
87468.1(a)(14)
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To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement is not being met as evidenced by:
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Licensee to conduct an in-service on personal rights and forward proof to LPA by POC due date.
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Based on observation and interviews conducted, Licensee failed to ensure R1 had access to the resident's phone. Staff removed the resident's phone and LPA observed blocked family member's number on phone. This poses an immediate health and safety risk to resident's 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 5
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
02/28/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250228162254

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:
08:21 AM
MET WITH:Monica WestphalnTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Facility is allowing resident to mix alcohol with medications
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to deliver findings on the above allegation. LPAs were 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 and witnesses as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that facility is allowing resident to mix alcohol with medications, the investigation revealed the following: Resident 1's physician report dated 08/13/2024 indicated a diagnosis of Dementia and not allowed to drink alcohol. Physician report dated 02/04/2025 indicated a Diagnosis of Dementia however stated resident was allowed alcohol. Five out of five witnesses state the R1 liked to drink and was known to have issues with alcohol. Five out of five witnesses indicate R1 would drink at happy hour and state she would be served non-alcoholic wine as well as a true wine. LPA toured the resident's room and did not observe any bottles of alcohol. R1 stated she did not have any alcohol in her room and that it had all been removed a while ago. Administrator indicates the physician order was changed CONTINUED ON LIC 9099C DATED 07/01/2025
Unsubstantiated
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: 4 of 5
Control Number 22-AS-20250228162254
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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to allow alcohol due to resident's aggressive behavior when denied alcohol. Based on interviews conducted and record review, the department is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
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: 5 of 5