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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:28:09 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
01/27/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250127090735
FACILITY NAME:SEVILLE OF SAN CLEMENTE, THEFACILITY NUMBER:
306006584
ADMINISTRATOR:TELLES, JUSTINFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:130CENSUS: 34DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Justin Telles - Executive Director TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility lacks supervision of Memory Care Residents
INVESTIGATION FINDINGS:
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On this day LIcensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and grated entry into the facility by Executive Director Justin Telles and explained the reason for the visit.

The Department received a complaint on 01/27/2025 and LPA Mendivil conducted the initial 10 day visit on 02/03/2025. LPA obtained copies of pertinent documents such as resident roster, staff schedule, and vigil memory care system alerts. LPA Mendivil also interviewed staff and residents. Regarding the allegations facility lacks supervision of Memory Care residents, the investigation revealed the following:

It was alleged the facility lacks supervision of Memory Care residents. Per review of resident roster Memory Care has 13 residents and a total for 4 staff for AM shift, 4 for PM and 2-3 for nocturnal shift. LPA Mendivil toured the facility and observed residents in a common area watching TV and a few in their rooms. There was staff present in the common area with the residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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 5
Control Number 22-AS-20250127090735
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 02/03/2025
NARRATIVE
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ED Justin stated the facility utilizes motion sensors that emit an alarm on all facility cell phones. ED explained that at night all rooms have sensors and staff is able to monitor movement. Based on interviews with 3 out of 3 staff state they conduct rounds on resident at minimum of hourly. Staff stated most residents are in the common areas during the day and if a resident stays in their room they will check on them hourly.

Therefore based on observations and interviews the allegation that facility lacks supervision in memory care is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.

An exit interview was conducted and a copy of this report this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/27/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250127090735

FACILITY NAME:SEVILLE OF SAN CLEMENTE, THEFACILITY NUMBER:
306006584
ADMINISTRATOR:TELLES, JUSTINFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:130CENSUS: 34DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Justin Telles - Executive Director TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not reporting resident falls in Memory Care
INVESTIGATION FINDINGS:
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On this day LIcensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and grated entry into the facility by Executive Director Justin Telles and explained the reason for the visit.

The Department received a complaint on 01/27/2025 and LPA Mendivil conducted the initial 10 day visit on 02/03/2025. LPA obtained copies of pertinent documents such as resident roster, staff schedule, and facility pull cord records. LPA Mendivil also interviewed staff and residents. Regarding the allegations facility is not reporting resident falls in Memory Care, the investigation revealed the following:

It was alleged the facility is not reporting falls in memory care. Per interviews with ED Justin, he stated that the facility uses LIC 624 Unusual/Serious Injury Report if there is a fall or someone is sent out to the hospital.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250127090735
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 02/03/2025
NARRATIVE
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Per review of Resident 1 (R1) file discharge papers from a hospital visit that diagnosed resident with a dislocated shoulder and head injury. Based on interviews with 3 out of 3 staff it was reported R1 had a fall about a month ago. Per review the Department did not receive LIC 624 for the incident.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that facility is not reporting falls in memory care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250127090735
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
Section Cited
CCR
87211(a)(1)(D)
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in... (D) Any incident which threatens the welfare, safety or health of any resident...
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Executive Director agreed to conduct an in service by POC due date and provide documentation to LPA by POC due date.
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This requirement was not met as evidence by facility did not report a fall for Resident 1 (R1). This poses a potential risks to persons 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5