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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006472
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:45:37 PM

Document Has Been Signed on 03/12/2025 03:45 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/
DIRECTOR:
PAOLI, FREDFACILITY TYPE:
740
ADDRESS:660 CAMINO DE LOS MARESTELEPHONE:
(949) 489-3400
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 190CENSUS: 86DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Fred PaoliTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/25/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 02/13/2025 indicated Resident 1 (R1) had an un-witnessed fall in the hallway and was observed to have hip pain. 911 was called and resident was transported to the hospital and was diagnosed with right hip fracture. Resident had surgery to repair hip and admitted back to the facility on 03/01/2025. Per physician report dated 11/05/2024, resident is diagnosed with Dementia. Resident assessment dated 01/31/2025 indicates fall concern. LPA observed no other documented falls. Administrator states resident is on frequent checks, four times per shift, when not in common area of memory care unit. LPA viewed the area where the fall took place and observed no concerns. LPA spoke with resident who appeared well taken care of and verbalized feeling safe at the facility.








Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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