San Clemente Villas By The Sea

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure that residents are administered their medications as prescribed Staff mismanage residents' medications

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records (MAR). Regarding the allegations that staff do not ensure that residents are administered their medications as prescribed and staff mismanage residents' medications, the investigation revealed the following: LPA toured resident rooms and memory care unit on two different occasions and did not observe any medications in rooms or common areas. Four out of five staff deny finding medications lying around. One staff stated finding a medication in the dining room one time. LPA reviewed the MAR for five residents. All five MAR's have documented reasons for missed medications. Resithe state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260421085522

Allegation investigated: Staff member worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff. Regarding the allegation that staff member worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care, the investigation revealed the following: Five out of five staff interviewed deny any knowledge of a staff being present under the influence. Five out of five staff deny any staff sleeping in the facility before their shift. Administrator indicates no knowledge as well and confirms there have been no write-ups or terminations for this type of behavior. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated,the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260420154329

Allegation investigated: Facility gave resident another resident's psychotropic meds which resulted in hospitalization

Licensing Program Analyst (LPA) Kimberly Lyman conducte an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation that facility gave resident another resident's psychotropic meds which resulted in hospitalization, the investigation revealed the following: Facility self reported an incident on 09/04/2024 where Resident 1 (R1) was incorrectly given another resident's Seroquel, Risperidone, and Lorazapam. R1 was transferred to Mission Hospital for observation and remained admitted until 09/08/2024. Facility notes indicate Mission Hospital stated there were no adverse effects from the medication error. Staff 1 (S1) was provided a written warning from the facility. Review of records showed the staff had received medication training frothe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 22-AS-20240923110559

Allegation investigated: Staff do not communicate changes in care to authorized representative Staff not providing records to the authorized representative

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Long Term Care Ombudsman Patricia McKeon was present as well. During the visit, LPA interviewed Administrator as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that staff do not communicate changes in care to authorized representative and staff not providing records to the authorized representative, the investigation revealed the following: Resident 1 (R1) was re-assessed on 03/24/2026 and 04/01/2026 after two instances of elopement out of the facility in March 2026. Per physician reports dated 10/02/2022 and 03/24/2026, R1 is diagnosed with Mild Cognitive Impairment and unable to leave the facility unassisted. Both assessments were provided to responsible party and time stamps on documents confirthe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 22-AS-20260402125930

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility is charging a resident for services not rendered

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was 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 and residents. Regarding the allegation that facility is charging a resident for services not rendered, the investigation revealed the following: Information reported to the department indicated Resident 1 (R1) is being charged for dressing assistance. LPA reviewed resident assessment dated 12/17/2024 which showed that the resident is not being charged for dressing. Resident and staff denied staff are assisting with dressing. Based on record review and interviews conducted, the allegation is deemed UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facilitthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 22-AS-20250619121530

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff communicate in a language that residents are unable to understand Staff are mismanaging residents' medications

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff. Regarding the allegations that staff communicate in a language that residents are unable to understand and staff are mismanaging residents' medications, the investigation revealed the following: Facility Executive Director indicates staff are to speak to residents in a language they are able to understand. Most speak English to residents but Spanish speaking residents prefer the staff speak Spanish with them. Eight out of nine staff state residents are able to understand the staff and there is no issue with language. Staff 1 (S1) indicates the language barrier is directed at the staff and not the residents. LPA unsuccessfully attempted interviews with memorythe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 22-AS-20250424120311

Allegation investigated: Staff are not providing timely access to a resident's personal records.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Fred Paoli was present and assisted with the visit after being presented with the allegation under review. During the visit, LPA requested and obtained the facility's current resident census, staff roster along with records maintained at the facility for resident R1. One staff interview conducted. CONTINUED ON FORM LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2025 · control 22-AS-20250313134523

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility is not providing care and supervision to residents Incontinence care is not being provided to residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that incontinence care is not being provided to residents and facility is not providing care and supervision to residents, the investigation revealed the following: Five out of five staff state incontinence care is provided at least every 2 hours and residents are not left soiled. All staff interviewed state no incidents of coming on shift and finding a resident soiled. Two out of five staff state instances of working with only one other person making care to residents difficult. LPA toured the memory care unit on two different occasions andthe state’s words, verbatim · CDSS document, Feb 10, 2025 · control 22-AS-20250107103931

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.