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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006472
Report Date: 07/19/2024
Date Signed: 07/22/2024 03:36:37 PM


Document Has Been Signed on 07/22/2024 03:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SEAFACILITY NUMBER:
306006472
ADMINISTRATOR:KEPHART, LAURAFACILITY TYPE:
740
ADDRESS:660 CAMINO DE LOS MARESTELEPHONE:
(949) 489-3400
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:190CENSUS: 116DATE:
07/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Laura Kephart and Cara DeiroTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator Laura Kephart. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 11/21/2023 for a capacity of 25 ambulatory, 125 non-ambulatory and 40 bedridden residents. Facility appears clean and sanitary and utilizes solar panels.
LPA Lyman along with Administrator and Director of Health Services toured the facility at 10:56 AM and observed the following:
Structure: Facility is a three story building with an assisted living and a memory care unit. Facility houses a gym, salon, library and activity room. Living Room/ Dining Room: Adequate seating is available in the common areas including multiple seating areas throughout the facility. There are three different dining rooms including a bistro to serve the residents. Bedrooms Residents: Resident rooms are equipped with resident's personal furnishings. Facility will supply furnishings to residents who arrive without personal furnishings. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Residents all have private bathrooms located inside resident rooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Residents order off a menu with varied choices Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested operational. Fire extinguishers are mounted and charged. Facility tests carbon monoxide detectors and fire extinguishers in house and contracts with an outside business for sprinklers and smoke detectors. Appliances: Facility appliances as well as laundry are clean and operational. Water Temperature: Tested and recorded between 112.2 and 118.6 degrees F. in tested bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medications are stored and locked in the Wellness center. CONTINUED ON LIC 809C DATED 07/19/2024.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/19/2024
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Facility uses electronic medication administration record. Resident & Staff File: Records are stored secured in the business office. Reading Material, Games, and Equipment: Facility provides activities including exercise, games, happy hour and outings in the community. Outside Areas: LPA observed a clean shaded outside area with a pool secured by a 5 foot fence. Fire Clearance: Approved for 25 ambulatory, 125 non ambulatory and 40 bedridden residents on 02/06/2024.









Facility is ready to be licensed.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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