The Seville of San Clemente

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Seville of San Clemente. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 130 non-ambulatory of which 20 may be bedridden. Facility has an approved hospice waiver for 20 residents and the facility currently has 10 residents on hospice care. Dyan Summerell has an administrator certificate expiring on 12/23/2027. LPAs Lyman and Mendivil along with Life Enrichment Director Hector Gonzalez toured the facility at 11:45 AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of one main building housing assisted living and memory care residents. LPAs observed kitchen, dining room, beauty salon, activity areas, gym and outside areas. Resident rooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 113.3 and 114.9 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissor as well as a first aid pamphlet. LPAs observed no toxins unsecured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and all were in range. LPAs observed emergency evacuation chair. Smoke detectors and fire inspections are conducted by an outside company, Hiller with the last inspection date of 07/10/2026. CONTINUED ON LIC 809C DATED 08/06/2026 Fire extinguishers are fully charged. LPAs toured the outside grounds and there is ample shaded seating for residents in multiple patio areas. LPAs observed emergency food and water. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games, exercise, and crafts. LPAs observed residents participating in activities during the visit. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen, and criminal record clearance. LPA observed five out of seven staff files did not contain proof of required annual training. LPAs reviewed select medications during the visit. Medications are secured in a medication cart and facility uses an electronic medication administration record. Medications appear to be administered per physician order. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Aug 6, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports received by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 06/09/2026 indicated Resident 1 (R1) did not receive prescribed medications Trazadone, Donezepil, and Escitalopram due to Staff 1 (S1) forgetting to administer the medications. No after effects noted. Per physician report dated 09/07/2025, R1 is diagnosed with Dementia and is on med management at the facility. S1 was written up and provided re-training. Incident report dated 06/12/2026 indicated R2 was administered a nasal spray inhalation medication that was prescribed to the resident's spouse. Staff 2 (S2) administered the medication as the spouse told the staff to administer. There were no after effects. Per physician report dated 12/01/2025, R2's primary diagnosis is Hypertension. S2 was terminated. Incident report dated 06/23/2026 indicated R3 missed medication Guaifensin oral liquid from 06/24-07/01/2026 due to medication not being checked in on time upon delivery to the facility. The resident had no after effects. Per physician report dated 09/07/2025, R3 has a primary diagnosis of Chronic Obstructive Pulmonary Disease. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Jul 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 4, 2026

Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated..., with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This req is not met as evidenced by: Based on record review, Licensee failed to ensure medications were properly administered to R1, R2 and R3 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2026

Plan of correction: Licensee to provide medication re-training to staff and forward proof to LPA by POC due date.

Allegation investigated: Lack of supervision resulted in resident being left outside Facility did not notify resident's responsible party of change in resident's reappraisal

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 facility and interviewed staff and witnesses. Regarding the allegations that lack of supervision resulted in resident being left outside and facility did not notify resident's responsible party of change in resident's reappraisal, the investigation revealed the following: On 01/13/2026, Resident 1 (R1) was observed by Staff 1 (S1) outside on a front patio at approximately 6:05 AM in pajamas. R1 was unable to get back inside the facility due to a key fob being necessary as doors are locked in the overnight hours. S1 was coming into work when the resident was observed outside. Resident was determined to be ice cold but no injuries noted. Resident's room is located in the rear of the building and there are no staff at the front desk during overnight hours. It has not been determined how long the resident was outside. R1 was reassessed December 2, 2025. Responsible party indicates not being informed of the changes. CONTINUED ON LIC 9099C DATED 03/18/2026 Substantiated Facility documentation obtained confirms that the responsible party was not informed of the changes nor signed the plan dated 12/02/2025 at time of implementation. Based on interviews conducted and record review, the allegations are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and violations have 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.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 22-AS-20260114091113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 19, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure care and supervision was provided to resident. R1 was locked outside on a patio in the early morning hours which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee to forward a detailed plan as to how to ensure the saftey of residents overnight and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Apr 1, 2026

For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative.., written notice of the rate increase within two business days after initially providing services at the new level of care. This req is not met as evidenced by: Based on interviews conducted and record review, Licensee did not provide written notice to responsible party of increase in fees. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee to submit a plan to ensure responsible parties are notified of rate increases timely and forward proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report submitted to Licensing on March 17, 2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Upon entry into the facility, LPA observed floor construction and the area adjacent to the dining room taped off (photo). Staff indicate replacement of floor tiles had been going on for about two weeks. The department did not receive notification of construction, time frame for work or impact on resident safety. Incident report dated 03/13/2026 indicated that a credit card was opened in the name of Resident 1 (R1) and purchases had been made and delivered to the facility. LPA interviewed R1's spouse who provided conflicting information regarding the situation. R1's family member had advised facility of intent to file a police report but facility is unsure as to whether the report was filed. Facility investigation remains ongoing. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 1, 2026

Each licensee shall furnish to the licensing agency such reports...(1)A written report shall be submitted to the licensing agency..Any incident which threatens the welfare, safety or health of any resident..This requirement is not met as evidenced by: Based on observation, Licensee failed to ensure floor construction was reported to the department which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licenee to forward the construction plan including time frame and impact to residents to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 01/16/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 01/09/2025 indicated Resident 1 (R1) was found on the floor in the resident's room with a noticeable bump on the head. Hospice was notified and staff state there were no injuries from the fall. Resident is noted to be a fall risk per facility assessment. In conjunction with complaint visit 22-AS-20260114091113, LPA reviewed records. Facility did not submit an incident report for the incident noted in the complaint where R2 was found locked outside the facility. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Jan 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 26, 2026

Each licensee shall furnish to the licensing agency such reports as the Department may require...Any incident which threatens the welfare, safety or health of any resident... or unexplained absence of any resident. This req is not met as evidenced by: Based on record review, Licensee failed to ensure incident involving R2 being locked outside was provided to the department. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee to submit incident report to the department by POC due date.

Allegation investigated: Facility did not administer medications as prescribed. Facility did not properly secure dangerous items. Facility did not properly assess residents.

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 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. 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.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 22-AS-20250220153051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 29, 2025

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: 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.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Medication in-service last conducted and cleared on 8/8/25. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Aug 29, 2025

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: 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.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 20, 2025

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: Based on observation, 31 prescription medications were observed and removed from R2's apartment.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: 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.

Allegation investigated: Staff mismanaged residents’ medications Staff did not assist resident with care needs in a timely manner

Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to deliver the findings of the complaint investigation into the allegations listed above. LPAs met with Director of Health and Wellness Lori Salas and explained the reason for the visit. During the course of the investigation, LPA inspected the facility, interviewed staff and residents, obtained and reviewed resident and staff records. The investigation revealed the following: It was alleged that staff mismanaged residents’ medication. LPA reviewed the Medication Administration Record (MAR) dated May 1, 2025, to May 16, 2025, for R1. LPA additionally reviewed the prescription for R1’s Prednisone 20 MG tablet, which was prescribed on May 15, 2025, and states that R1 is to receive two tablets by mouth daily for three days. Per the MAR, R1 received her first dosage of her prescribed Prednisone 20 MG tablet medication on May 16, 2025. CONTINUED ON LIC9099-C Substantiated R1 only received one dosage of her Prednisone 20 MG tablet medication since she was hospitalized on May 16, 2025, so there should be four remaining tablets for R1’s Prednisone 20 MG tablet medication. However, per the facility’s medication release form dated May 20, 2025, which was provided to R1’s family, there were only two tablets remaining for R1’s Prednisone 20 MG tablet medication. Therefore, a medication occurred on May 16, 2025, in which R1 received double her dosage for her Prednisone 20 MG tablet medication. Furthermore, LPA reviewed an Internal Occurrence Report from the facility dated May 2, 2025. The Internal Occurrence Report describes how a facility staff mismanaged R1’s Ropinirole 3 MG tablet medication by giving R1 triple her prescribed dosage. Five out of six staff interviews conducted with staff that assist residents with medication confirmed a medication error occurred on May 2, 2025, in which R1 received triple her prescribed dosage for her Ropinirole 3 MG tablet medication. The facility’s Licensed Vocational Nurse (LVN) who was on duty on May 2, 2025, then assessed R1 after the medication error and did not note any adverse reactions. Facility staff then contacted R1’s Primary Care Physician (PCP) who advised the facility that R1 could remain in the community since R1 did not have any adverse reactions. Facility staff then continued to monitor R1s condition by monitoring R1’s blood pressure, heart rate, respiration, and temperature. R1’s family was also informed of the medication error. Based on interviews conducted and the evidence gathered, the Department obtained sufficient evidence to substantiate the allegation that staff mismanaged residents’ medication. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099D for the deficiency cited per Title 22 Division 6 of the California Code of Regulations. The investigation revealed the following: It was alleged that staff did not assist residents with care in a timely manner. LPA reviewed the call button response times dated March 8, 2025, to May 16, 2025, for R1. Per the call button response times, LPA observed that there were numerous occasions in which R1 had to wait extended periods of time to be assisted by facility staff after she pressed her call button. CONTINUED ON LIC9099-C For example, on March 8, 2025, it took the facility staff 47 minutes to respond to R1 after she pressed her call button. On March 17, 2025, it took the facility staff 62 minutes to respond to R1 after she pressed her call button. On March 21, 2025, it took the facility staff 61 minutes to respond to R1 after she pressed her call button. On April 4, 2025, it took the facility staff 42 minutes to respond to R1 after she pressed her call button. Additionally, on April 29, 2025, it took the facility staff 47 minutes to respond to R1 after she pressed her call buttons. LPA also conducted six staff interviews with staff who are responsible for responding to residents when they press call buttons. Four out of the six staff interviews conducted stated that there have been days when residents would have to wait extended periods of time to be assisted after pressing their call buttons due to staffing issues. LPA reviewed the staffing schedules for the months of March 2025, and April 2025, and determined that there were insufficient staff present on the days R1 had to wait extended periods of time to be assisted. Based on interviews conducted and the evidence gathered, the Department obtained sufficient evidence to substantiate the allegation that staff did not assist residents with care in a timely manner. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099D for the deficiency cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Director of Health and Wellness Lori Salas, and the report was explained. A copy of the report and Appeal Rights were also provided. LPA reviewed the Death Report dated May 21, 2025, which states that R1 was transported to the hospital after experiencing left arm pain and vomiting. The Death Report further states that R1 passed away at the hospital. LPA reviewed the medical records from Providence Mission Hospital dated May 16, 2025, to May 17, 2025, for R1. Per the medical records, R1 was admitted to Providence Mission Hospital on May 16, 2025, with is diagnoses of intermittent complete heart block, hiatal hernia, and acute hypoxemic respiratory failure. LPA reviewed the County of Orange Health Care Agency certificate of death for R1. Per the certificate of death, R1’s cause of death was cardiac arrest, respiratory failure, and aspiration pneumonia. LPA reviewed the Medication Administration Record (MAR) dated May 1, 2025, to May 16, 2025. LPA observed there was a medication error on R1’s prednisone 20 MG tablet medication in which R1 received double her prescribed dosage on May 16, 2025. However, per the review of the medical records and the certificate of death, the medication error was not listed as the immediate cause of death, or the underlying cause of death, for R1. Based on the evidence gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. The investigation revealed the following: It was alleged that staff did not answer facility telephone. During the course of the investigation, LPA was informed that the facility has multiple telephone numbers that are all forwarded to the facility’s 24-hour line. These telephone numbers include (949) 227-3185, (949) 216-5406, (949) 236-6135 and residents’ families can call these telephone numbers to reach the facility staff during, and after normal business hours. On July 17, 2025, at 11:30 PM, LPA called the telephone number (949) 227-3185. Facility staff answered the telephone after 23 seconds. On July 18, 2025, at 6:55 AM, LPA called the telephone number (949) 227-3185. Facility staff answered the telephone after 13 seconds. CONTINUED ON LIC9099-C Based on the evidence gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Director of Health and Wellness Lori Salas, and a copy of the report was provided. Six out of six resident interviews conducted also confirmed that they currently have had access to hot water for personal care. LPA tested the hot water temperature in seven resident bathrooms, including R1’s former unit, which tested between 115.1 to 116.7 degrees Fahrenheit. LPA reviewed the facility’s hot water temperature logs, maintenance notes, conducted an interview with the maintenance personnel, and was informed there was an issue with the hot water temperature on May 5, 2025. However, LPA was informed that maintenance personnel discovered what the issue was and were able to fix it on the same day. The maintenance personnel reported that no further issues with the hot water temperature have occurred at the facility since then. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Director of Health and Wellness Lori Salas, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 22-AS-20250523142433

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 8, 2025

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not evidenced by: Based on documents and interviews, the Licensee did not ensure R1 received her medication as prescribed. Facility staff mismanaged R1’s medication on May 2, 2025, and May 16, 2025, by providing R1 the incorrect dosage of her routine medications. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: The Licensee stated they will provide in-house medication training with all staff addressing importance of giving the residents the correct dosage of the prescribed medications and their quality assurance procedures. The proof of training will be submitted to the LPA via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 8, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not evidenced by: Based on documents and interviews, the Licensee did not ensure that R1 was assisted in a timely manner after pressing her call button. There are numerous dates documented which demonstrate that R1 would have to wait extended periods of time to be assisted by facility staff after pressing her call button. This poses an immediate health and safety risk to people in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: The Licensee stated they will hire sufficient staff to meet the needs of resident in care and submit a written plan on how the facility intends to ensure residents will receive timely response from the staff to be assisted after pressing their call buttons for assistance. Th written plan will be submitted to LPA via email or fax by POC date.

Allegation investigated: Licensee does not ensure the facility has certified administrator

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 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.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 22-AS-20250618104742

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(k)(1) · Plan of correction due date: Aug 14, 2025

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: 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.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Licensee to forward an updated LIC 308/ resume to LPA by POC due date. Licensee provided a copy of new administrator's certificate.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Seville of San Clemente. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 130 non-ambulatory of which 20 may be bedridden. Facility has an approved hospice waiver for 20 residents and the facility currently has 7 residents on hospice care. Roger Endert has an administrator certificate expiring on 04/06/2026. LPAs Lyman and Mendivil along with Administrator Endert and Wellness Director Lori Salas toured the facility at 9:06 AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of one main building housing assisted living and memory care residents. LPAs observed kitchen, dining room, beauty salon, activity areas, gym and outside areas. Resident rooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 113.3 and 116.2 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 7 minutes for emergency cord pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissor. LPAs observed no toxins unsecured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and all were in range. LPAs observed there is a emergency evacuation chair in one stairwell only. Smoke detectors and fire inspections are conducted by an outside company, Hiller with the last inspection date of 07/01/2025. CONTINUED ON LIC 809C DATED 07/31/2025 Fire extinguishers are fully charged. LPAs toured the outside grounds and there is ample shaded seating for residents in multiple patio areas. LPAs observed ample emergency food. LPAs reviewed the infection control plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games, exercise, and crafts. LPAs observed residents participating in activities during the visit. LPAs spoke with residents during the visit who stated satisfaction with facility services. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen, and criminal record clearance. LPA observed six out of six staff files did not contain proof of required annual training and one out of six do not have proof of TB test in the file. LPAs reviewed select medications during the visit. Medications are secured in a medication cart and facility uses an electronic medication administration record. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Jul 31, 2025

Allegation investigated: Facility has insufficient staffing to meet the needs of residents in care

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 has insufficient staffing to met the needs of the residents, the investigation revealed the following: Facility schedule indicates six caregivers and two med techs for 1st shift, six caregivers and one med tech for second shift and 4 staff on NOC shift. LPA observed adequate staffing on two different visits. Five out of seven staff state staffing levels are adequate and resident needs are being met. Four out of four residents state staffing levels are OK and have improved slowly since the facility opened. Four out of four residents indicate their needs are being met. Based on observations and interviews, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed 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. An exit interview was conducted and a copy of this report this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 24, 2025 · control 22-AS-20250305123959

Allegation investigated: Facility lacks supervision of Memory Care Residents

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 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. 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.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 22-AS-20250127090735

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 10, 2025

(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... 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.the state’s words, verbatim · CDSS document, Feb 3, 2025

Plan of correction: Executive Director agreed to conduct an in service by POC due date and provide documentation to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjuction with complaint control # 22-AS-20250127090735. LPA was greeted and granted entry into the facility by Executive Director Justin Telles and explained the reason for the visit. LPA Mendivil toured the entry way of the facility. LPA Mendivil did not observe the PUB 475 in the entry of the facility or in a place that is visible to the public. LPA Mendivil advised ED Justin of the missing and required poster. ED stated they had a poster but unsure of whereabouts currently. Based on observations made during today's visit a deficiency is being cited per Title 22. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Feb 10, 2025

2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:(A) Licensees may use the RCFE Poster (PUB 475) or may develop their own poster A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This requirement was not met as evidence by LPA did not observe PUB 475 in entryway.the state’s words, verbatim · CDSS document, Feb 3, 2025

Plan of correction: ED corrected during visit.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator Justin Telles. Director of Compliance Angel Ascencio and Assistant Superintendent Steve McVicar were present as well. An initial application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing on 04/26/2024 for a capacity of 110 non-ambulatory and 20 bedridden residents. Upon entry, facility appears clean and sanitary. Facility has all required postings at entrance. Administrator Justin Telles has an administrator certificate expiring on 10/29/2024. LPA Lyman along with the management team toured the facility at 1:08 PM and observed the following: Structure: Facility is a two story building housing 63 assisted living apartments and 24 memory care apartments. Memory Care has delayed egress exits which were operational during today's visit. LPA observed multiple activity rooms and visiting areas as well as Wellness center, hair salon and movie theater. Common Areas: Adequate seating is available in multiple common areas and patios. Apartments: Residents: Residents will provide their own furnishings as well as linens and supplies. Facility has items in stock to provide as needed and can assist with furnishings upon request. Bathrooms: All resident bathrooms have a working toilet/ wash basin/ shower as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables and will maintain food supply once residents move in. LPA observed a dining room/ bar in the assisted living and a separate dining room in the Memory Care unit as well as a private dining room. Smoke Detectors: Smoke detectors/ carbon monoxide detectors to be tested by an outside company. Facility provided documentation of smoke detector testing upon installation. Fire extinguishers are fully charged. Appliances: LPA observed laundry areas in the facility. Water Temperature: Tested and recorded between 105.9 and 119.1 degrees F. in tested restrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Facility has a generator for emergencies. CONTINUED ON LIC 809C DATED 08/19/2024. Medications, First-Aid Kit & Book: First aid kit observed contained all required items as well as a first aid manual. Medication is stored in a locked medication carts. Facility to use an electronic medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in Administrator office. Reading Material, Games, and Equipment: LPA observed an activity schedule with activities such as games, happy hour and exercise. LPA observed the facility van for outings in the community. Outdoor Space: LPA observed clean, shaded outside areas with ample seating for residents. Facility has a pool secured at 5 feet by a fence with entry granted by a key fob. Fire Clearance: Approved for 110 non-ambulatory and 20 bedridden residents on 07/25/2024. Component III waived due to Administrator experience. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 130 Interview Method: Telephone interview On 8/9/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 9, 2024