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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006472
Report Date: 02/10/2025
Date Signed: 02/10/2025 02:49:53 PM

Unsubstantiated


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
01/07/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250107103931
FACILITY NAME:SAN CLEMENTE VILLAS BY THE SEAFACILITY NUMBER:
306006472
ADMINISTRATOR:PAOLI, FREDFACILITY TYPE:
740
ADDRESS:660 CAMINO DE LOS MARESTELEPHONE:
(949) 489-3400
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:190CENSUS: 89DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Fred PaoliTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not providing care and supervision to residents
Incontinence care is not being provided to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. 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 memory care unit and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that incontinence care is not being provided to residents and facility is not providing care and supervision to residents, the investigation revealed the following: Five out of five staff state incontinence care is provided at least every 2 hours and residents are not left soiled. All staff interviewed state no incidents of coming on shift and finding a resident soiled. Two out of five staff state instances of working with only one other person making care to residents difficult. LPA toured the memory care unit on two different occasions and observed all residents had blankets and temperatures were between 71-75 degrees F in resident rooms. LPA interviewed Resident 1 (R1) who stated he received his pendant when he moved in and that staff respond to the pendant timely. CONTINUED ON LIC 9099C DATED 02/10/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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 2
Control Number 22-AS-20250107103931
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: SAN CLEMENTE VILLAS BY THE SEA
FACILITY NUMBER: 306006472
VISIT DATE: 02/10/2025
NARRATIVE
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Facility documentation indicates that R2 was sent out to the hospital on 12/18/2024 due to abdominal pain. Resident has been out of the facility since then admitted to a skilled nursing facility after colon surgery. Physician report dated 05/11/2024 indicates resident is able to leave the facility unassisted and manages own medications. Facility meal check in paperwork shows the resident did not check in for meals a total of 5 non-consecutive days between 12/01-12/17/ 2024. Based on records reviewed and interviews conducted, LPA 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 and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2