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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006472
Report Date: 03/18/2025
Date Signed: 03/18/2025 12:25:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/13/2025 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250313134523
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: 88DATE:
03/18/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Fred Paoli, Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not providing timely access to a resident's personal records.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Fred Paoli was present and assisted with the visit after being presented with the allegation under review.

During the visit, LPA requested and obtained the facility's current resident census, staff roster along with records maintained at the facility for resident R1. One staff interview conducted.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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-20250313134523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAN CLEMENTE VILLAS BY THE SEA
FACILITY NUMBER: 306006472
VISIT DATE: 03/18/2025
NARRATIVE
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CONTINUED FROM FORM LIC9099
Per the records reviewed along with the death report submitted by the facility on May 10, 2024, R1 passed away under hospice continuous care on April 28, 2024. On or around February 26, 2025, a law firm representing the late resident reached out to facility staff to request records from R1's period of admission at the facility. Per facility staff, records were not submitted in response yet after a follow-up email was sent during the week of March 9 to March 15, 2025. Facility staff indicated that a facility audit on the records requested was under way and had delayed the submission of records. Per the documentation reviewed, the law firm made the request and submitted all supporting evidence to demonstrate the request was legitimate, as well as issued a payment for clerical and reproduction costs by check dated February 25, 2025. Per Title 22 regulations, "Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.".

Based on the evidence gathered, facility staff failed to meet that requirement. The allegation that "Staff are not providing timely access to a resident's personal records" is therefore substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on an attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250313134523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAN CLEMENTE VILLAS BY THE SEA
FACILITY NUMBER: 306006472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87468.2(a)(19)
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Per the California Code of Regulations Section 87468.2(a)(19) listing Additional Personal Rights of Residents in Privately Operated Facilities: "residents(....) shall have all of the following personal rights: (...) (19) To have prompt access to review all of their records (...) Photocopied records shall be
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Facility staff will inform LPA that records requested have been provided before the plan of corrections due date.
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provided within two (2) business days (....)". This requirement was not met as evidenced by the additional delay evidenced during the present visit. This constitutes a potential risk to the health, safety and personal rights of individuals 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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3