306006584-8-7-2025-22-AS-SSAS-DKKQ88-20250815115618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 08/07/2025
Date Signed: 08/07/2025 10:11:26 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/23/2025 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250523142433

FACILITY NAME:	SEVILLE OF SAN CLEMENTE, THE		FACILITY NUMBER:	306006584
ADMINISTRATOR:	TELLES, JUSTIN		FACILITY TYPE:	740
ADDRESS:	2421 CALLE FRONTERA		TELEPHONE:	(760) 382-3463
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	130	CENSUS: 67	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director of Health and Wellness Lori Salas		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEVILLE OF SAN CLEMENTE, THE	FACILITY NUMBER: 306006584
	VISIT DATE: 08/07/2025

NARRATIVE

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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

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEVILLE OF SAN CLEMENTE, THE	FACILITY NUMBER: 306006584
	VISIT DATE: 08/07/2025

NARRATIVE

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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.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 08/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/08/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
Type A 08/08/2025 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/23/2025 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250523142433

FACILITY NAME:	SEVILLE OF SAN CLEMENTE, THE		FACILITY NUMBER:	306006584
ADMINISTRATOR:	TELLES, JUSTIN		FACILITY TYPE:	740
ADDRESS:	2421 CALLE FRONTERA		TELEPHONE:	(760) 382-3463
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	130	CENSUS:	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director of Health and Wellness Lori Salas		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Questionable death
Staff did not answer facility telephone

INVESTIGATION FINDINGS:

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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. LPA 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 the mismanagement of medication resulted in a questionable death. Resident #1 (R1) was admitted to the facility on December 30, 2024. LPA reviewed R1’s Physician Report dated December 27, 2024, which states that R1 had a diagnosis of paroxysmal atrial tachycardia, arthralgia of multiple sites bilateral, gastroesophageal reflux disease, hypothyroidism, hypertension, osteoporosis, restless leg syndrome, anxiety, chronic pain syndrome, and osteoarthritis.
CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEVILLE OF SAN CLEMENTE, THE	FACILITY NUMBER: 306006584
	VISIT DATE: 08/07/2025

NARRATIVE

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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

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEVILLE OF SAN CLEMENTE, THE	FACILITY NUMBER: 306006584
	VISIT DATE: 08/07/2025

NARRATIVE

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SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/23/2025 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250523142433

FACILITY NAME:	SEVILLE OF SAN CLEMENTE, THE		FACILITY NUMBER:	306006584
ADMINISTRATOR:	TELLES, JUSTIN		FACILITY TYPE:	740
ADDRESS:	2421 CALLE FRONTERA		TELEPHONE:	(760) 382-3463
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	130	CENSUS:	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director of Health and Wellness Lori Salas		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff did not ensure resident had access to hot water for personal care

INVESTIGATION FINDINGS:

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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 allegation listed above. LPA 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 did not ensure resident had access to hot water for personal care. During LPAs inspection conducted on June 13, 2025, LPA conducted six resident interviews and checked the hot water temperature in seven resident bathrooms, which are in each of the resident’s unit. Six out of six resident interviews conducted denied having any current or past issues with having access to hot water for personal care.
CONTINUED ON LIC9099-C

Unfounded

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 22-AS-20250523142433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEVILLE OF SAN CLEMENTE, THE	FACILITY NUMBER: 306006584
	VISIT DATE: 08/07/2025

NARRATIVE

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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.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

Page: 9 of 9