SEVILLE OF SAN CLEMENTE, THE

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in five out of seven staff without required annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2026 Plan of Correction Licensee to conduct training and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Jul 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Mar 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

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.

Official 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.

Deadline recorded: Apr 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Apr 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee to submit incident report to the department by POC due date.

Deadline recorded: Jan 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Medication in-service last conducted and cleared on 8/8/25. Deficiency cleared.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one out of six staff without a TB screen in the file which poses a potential health, safety or personal rights risk to persons in care. Staff 5 does not have a TB test in file.

Official plan of correction

POC Due Date: 08/14/2025 Plan of Correction Licensee to obtain TB test for Staff 5 and forward proof to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in six out of six staff without 4 hours of training in postural support, restricted health conditions and hospice which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2025 Plan of Correction Licensee to conduct training and forward proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2025 Plan of Correction Licensee to conduct an emergency drill and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87407(k)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Aug 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

ED corrected during visit.

Deadline recorded: Feb 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

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

Deadline recorded: Feb 10, 2025. A deadline is not proof that correction was completed.