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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006472
Report Date: 04/09/2026
Date Signed: 04/09/2026 02:56:55 PM

Unfounded


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
04/02/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260402125930
FACILITY NAME:SAN CLEMENTE VILLAS BY THE SEAFACILITY NUMBER:
306006472
ADMINISTRATOR:MARION, MICHAELFACILITY TYPE:
740
ADDRESS:660 CAMINO DE LOS MARESTELEPHONE:
(949) 489-3400
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:190CENSUS: 86DATE:
04/09/2026
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mike MarionTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff do not communicate changes in care to authorized representative
Staff not providing records to the authorized representative
INVESTIGATION FINDINGS:
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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 confirm the documents were provided. Facility administrator confirms a care plan meeting was conducted with responsible parties on 03/26/2026. LPA reviewed facility documentation outlining the care plan. Email CONTINUED ON LIC 9099C DATED 04/09/2026
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
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 2
Control Number 22-AS-20260402125930
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: SAN CLEMENTE VILLAS BY THE SEA
FACILITY NUMBER: 306006472
VISIT DATE: 04/09/2026
NARRATIVE
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correspondence indicates responsible party was informed of the care companion facility implemented. Email correspondence dated 04/03/2026 show additional requested documents were provided to the responsible party including incident report and updated physician report. Based on record review and interviews conducted, the allegations are 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 facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
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