<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006584
Report Date: 08/19/2024
Date Signed: 08/20/2024 06:57:33 AM

Document Has Been Signed on 08/20/2024 06:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
306006584
ADMINISTRATOR/
DIRECTOR:		TELLES, JUSTINFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 130CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Justin TellesTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2