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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006014
Report Date: 04/21/2026
Date Signed: 04/21/2026 12:51:29 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
06/09/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250609081414
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: 37DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Joshua MartinezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained an unexplained injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman 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, the Department toured the facility and interviewed staff and witnesses as well as reviewed and obtained documentation such as medical records. Regarding the allegation that resident sustained an unexplained injury, the investigation revealed the following:

Resident 1 (R1) was admitted into the facility on October 02, 2022. Service plan dated October 02, 2022, showed resident’s level of assistance with transferring and mobility was deemed extensive. Per R1’s physician report dated August 03, 2023, R1 had a diagnosis of Dementia and motor impairment. On June 04, 2025, the resident’s family noticed that the resident appeared to be in pain. Resident stated feeling pain in knee and family member noticed bruising on knees and toes. CONTINUED ON LIC 9099C DATED 04/21/2026
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
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 6
Control Number 22-AS-20250609081414
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: 04/21/2026
NARRATIVE
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Facility staff denied any falls had occurred. Responsible party set up a meeting with physician and an X-Ray was ordered. On June 06, 2025, the X-Ray revealed a displaced femur fracture and resident was transported to the hospital and scheduled for surgery. When family spoke to a physician assistant, they were told the fracture R1 sustained most likely resulted from a mechanical fall. On June 06, 2025, upon hospitalization, R1 was noted to have two wounds, one on the groin and the other on the right heel that had not been reported or documented by facility staff.
Interviews with staff revealed it is unclear how R1 sustained a fracture while in care and the facility has no reported record of the resident falling. Four out of four staff, Director of Nursing and Administrator all deny R1 had a fall resulting in the fracture. Staff state all falls are reported and R1 had falls in the past which were reported. Staff stated they had difficulty with transfers due to the resident’s weight and the resident would require 2-3 staff for transfers. Staff 1 (S1) indicates reporting to family by text on June 04, 2025, that the resident’s knee appeared swollen. Facility did not subsequently follow up on the resident’s swollen knee nor seek medical attention.

The Department reviewed R1’s medical records for June 06, 2025, through June 23, 2025. Records showed hospital documented “Suspected elder neglect” saying there is a community acquired pressure related deep tissue injury in the right heel which was discovered during admission. Resident was diagnosed with a right knee periprosthetic fracture. The treatment plan indicates R1 was to be admitted for orthopedic surgical stabilization, pain management, medical management, postoperative physical therapy and orthopedic aftercare.
Per National Institute of Health (NIH), “This type of distal femur “periprosthetic” (the area immediately around an artificial body part (prosthesis or implant) fracture is usually caused by significant force on a vulnerable bone around a knee replacement, most commonly from a fall or twisting injury.” Upon Department review of records, there is no documentation of severe osteoporosis for R1 or any other condition that would, on its own, cause a fracture of this nature to occur spontaneously without trauma. NIH indicates common reasons for a fracture of this sort would be a fall directly onto the knee or onto the side with the knee twisting, a forceful twisting of the leg during transfers or major trauma such as a car accident. During staff interviews it was reported that the resident’s weight could be a reason for the fracture. However, NIH states that there would need to be significant force for this type of fracture and some sort of physical fall would almost always be involved. CONTINUED ON LIC 9099C DATED 04/21/2026
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20250609081414
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: 04/21/2026
NARRATIVE
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Based on the information provided such as the physician’s report, medical history information, and medical records, it was determined that the periprostatic fracture is likely to have occurred by a fall or a significant twist and not due to the resident’s weight. The preponderance of evidence standard has been met. Therefore, the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

A Civil Penalty is pending determination by Community Care Licensing Division as per H&S Code 1569.49(f).

An exit interview was conducted with Administrator 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: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20250609081414
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: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2026
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This req is not met as evidenced by:
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Licensee to provide an in-service on care and supervision including transfers and forward proof to LPA by POC due date.
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Based on records reviewed and interviews conducted, Licensee failed to ensure care and supervision was provided to R1. R1 sustained an unexplained fracture as well as pressure injury while in care which poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED
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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: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
06/09/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250609081414

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: 37DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Joshua MartinezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
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Staff did not notify authorized representative of incident
Staff did not get timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman 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, the Department toured the facility and interviewed staff and witnesses as well as reviewed and obtained documentation such as medical records. Regarding the allegations that staff did not notify authorized representative of incident and staff did not get timely medical care for resident, the investigation revealed the following:
On June 04, 2025, S1 notified family by text that R1 had swelling on the knee. Family came to the facility and obtained a physician appointment and X-Ray for resident. R1 was diagnosed with a right knee fracture and scheduled for surgery. Five out of five staff deny knowledge of any fall contributing to the fracture and indicate the resident was heavy set and required 2-3 caregivers for transfer. Facility notified the Department of the CONTINUED ON LIC 9099C DATED 04/21/2026
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20250609081414
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: 04/21/2026
NARRATIVE
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incident on September 06, 2025, indicating that the resident had a swollen knee which resulted in the fracture. Facility indicated in the report that the fracture was due to the resident’s weight and not a fall. The report indicates there was no bruising, however the medical records show the resident had swelling and bruising on right knee and thigh. Records reviewed could not confirm when the fall occurred thus the Department is unable to determine if the authorized representative was notified timely or if medical attention was sought timely. Based on record review and interviews conducted, the Department is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator, and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6