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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006584
Report Date: 02/03/2025
Date Signed: 02/03/2025 02:26:38 PM

Document Has Been Signed on 02/03/2025 02:26 PM - 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: 33DATE:
02/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Justin Telles - Executive Director TIME VISIT/
INSPECTION COMPLETED:
03:45 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
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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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
Document Has Been Signed on 02/03/2025 02:26 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 02/03/2025 at 01:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
Section Cited
CCR
87468(c)(2)(A)

1
2
3
4
5
6
7
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
1
2
3
4
5
6
7
ED corrected during visit.
8
9
10
11
12
13
14
 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.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2