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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 08/19/2025
Date Signed: 08/19/2025 05:48:22 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
02/20/2025 and conducted by Evaluator Jessica Cho
COMPLAINT CONTROL NUMBER: 22-AS-20250220153051
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: 65DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Roger Endert- Executive Director TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility did not administer medications as prescribed.
Facility did not properly secure dangerous items.
Facility did not properly assess residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of continuing and concluding the complaint investigation into the above allegations. LPA met with Executive Director (ED) Roger Endert and explained the reason for the visit.

On Feburary 20, 2025, the Department received a complaint, and the investigation was initiated on Feburary 27, 2025 followed by subsequent visits on July 24, 2025 and August 19, 2025. During the course of the investigation, apartment inspections, medication audits, file reviews, interviews were conducted for six residents as well as interviews with four staff.

The investigation is as follows: Regarding the allegation, Facility did not administer medications as prescribed, it is alleged that staff were "pushed" to administer Trazadone without a doctor's order for Resident #1 (R1). Faclity received an order for R1's Trazadone on March 5, 2025 at 10:20am.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 6
Control Number 22-AS-20250220153051
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Medication in-service last conducted and cleared on 8/8/25. Deficiency cleared.
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Based on record review, two out of seven residents' medications, R2 and R3, were not given as prescribed which poses a potential Health and Safety risk to persons in care.
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Type B
08/29/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation (a) The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. This requirement was not met as evidenced by:
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ED and HWD stated that an Acknowledgement of Understanding of the said deficiency will be adhered and will also identify the persons responsible for conducting assessments to LPA via email by POC due date.
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Based on interviews and record review, S1 corroborated that assessments were conducted by self which violates the facility's plan of operation which poses a potential Health, Safety, and/or Personal Rights risk 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20250220153051
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental and Medical Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidenced by:
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31 medications were removed on 2/27/25. ED stated that proof of in-service regarding the importance of centrally storing medications and disinfectants will be submitted to LPA via email by POC due date.
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Based on observation, 31 prescription medications were observed and removed from R2's apartment.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/20/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250220153051

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: 65DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Roger Endert- Executive Director TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
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5
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7
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9
Facility did not maintain complete resident files.

INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of continuing and concluding the complaint investigation into the above allegations. LPA met with Executive Director (ED) Roger Endert and explained the reason for the visit.

On Feburary 20, 2025, the Department received a complaint, and the investigation was initiated on Feburary 27, 2025. During the course of the investigation, LPA conducted file reviews for seven residents as well as reviewed the emergency binder of 39 residents.

The investigation is as follows: Regarding the allegation, Facility did not maintain complete resident files, it is alleged that pertinent resident documentation was unable to be provided to emergency personnel. Based on the review of the resident records, facility maintained all requirement documents. LPA was shown by facility staff the location of the red emergency binder which was behind the receptionist's desk.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20250220153051
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 08/19/2025
NARRATIVE
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The emergency binder contained all necessary and pertinent information for all 39 residents which included the face sheets, allergies, healthcare directives, emergency contacts, diagnoses, and etc.
No concerns noted per review.

Therefore, this agency has investigated the complaint and based on the records that were reviewed, the allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Executive Director Roger Endert and Health and Wellness Director Lori Salas, and a copy of this report was provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20250220153051
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 08/19/2025
NARRATIVE
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Per review of R1's Order Summary Report for active orders, facility was administering five routine medications which did not include Trazadone as of February 27, 2025. LPA did not have sufficient corroborating evidence to conclude that facility was administering Trazadone between R1's start date of February 18, 2025 to March 5, 2025. In review of seven randomly selected residents' routine/PRN medications, two out of seven residents' medications were not given as prescribed: ten routine medications were not given for Resident #2 (R2) and four routine medications for Resident #3 (R3) for the month of February 2025. One out of six residents interviewed indicated that their PRN pain medication was not given as prescribed. One out of four staff confirmed that one resident's PRN pain medication was not given as it was unavailable.

Regarding the allegation, Facility did not properly secure dangerous items, LPA along with Resident Care Coordinator Stephanie Najera observed and removed 31 prescription medications from R2's apartment on February 27, 2025. Per review of the Medication Self-Administration Safety Screening dated January 13, 2025, R2 was to begin on the medication management program on February 25, 2025. Facility did not ensure dangerous items which includes medications were removed from R2's room prior to being on the program.

Regarding the allegation, Facility did not properly assess residents, it is alleged that the the Resident Care Coordinator was assessing residents in lieu of the Licensed Vocational Nurse. Staff #1 (S1) confirmed assessing three residents and indicated that it was the responsibility of a Licensed Vocational Nurse to perform this task which was corroborated per review of the job function description for the RCC and Health and Wellness Director.

Therefore, it is determined that there were sufficient corroborating evidence to substantiate the above allegations. Deficiencies are being issued on the attached LIC9099Ds.

An exit interview was conducted with Executive Director Roger Endert and Health and Wellness Director Lori Salas, and a copy of this report including the LIC9099-C, LIC9099Ds, LIC811s, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6