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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 07/31/2025
Date Signed: 07/31/2025 03:25:56 PM

Substantiated


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
06/18/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250618104742
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: 61DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Roger EndertTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee does not ensure the facility has certified administrator
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff. Regarding the allegation that Licensee does not ensure the facility has certified administrator, the investigation revealed the following: Information reported to LPA indicated that Staff 1 (S1) was no longer Administrator at the facility. Facility stated S1's last day was between 05/15-05/20/2025. The date of the initial complaint investigation was 06/24/2025 and facility had not notified LPA of the change. Based on interviews conducted and observation, the allegation 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 4
Control Number 22-AS-20250618104742
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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2025
Section Cited
CCR
87407(k)(1)
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Whenever a certified administrator.. relinquishes responsibility for administering a residential care facility for the elderly.. shall provide written notice, within thirty (30) days, to:
The local licensing office responsible for receiving information regarding personnel changes...This req is not met as evidenced by:
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Licensee to forward an updated LIC 308/ resume to LPA by POC due date. Licensee provided a copy of new administrator's certificate.
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Based on observation and interviews conducted, Licensee failed to provide notice of change of Administrator to the department which poses a potential health and safety risk to residents 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: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/18/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250618104742

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: 61DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Roger EndertTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure medication records are properly maintained
Staff due not ensure residents self administer medications once dispensed
Staff do not ensure expired, discontinued medications are properly discarded from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication destruction record. Regarding the allegations that staff do not ensure medication records are properly maintained, staff due not ensure residents self administer medications once dispensed and staff do not ensure expired discontinued medications are properly discarded from the facility, the investigation revealed the following: Five out of five staff confirm watching residents take their medications and not leaving the residents unsupervised. Five out of five staff deny ever finding medications on the ground or in resident rooms. LPA audited medications for select residents and observed no discrepencies. LPA observed medication destruction records and were observed to be in order. LPA observed medication training records during the investigation. Based on record review and observation, LPA is unable to corroborate the allegations. CONTINUED ON LIC 9099C DATED 07/31/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 4
Control Number 22-AS-20250618104742
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: 07/31/2025
NARRATIVE
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Therefore, the allegations are deemed UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.
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: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4