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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003005
Report Date: 09/25/2026
Date Signed: 09/25/2026 11:13:19 AM

Substantiated


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
09/04/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260904165443
FACILITY NAME:CALIFORNIA LIFESTYLES IIFACILITY NUMBER:
306003005
ADMINISTRATOR:ROY/SHEILA MOELLERFACILITY TYPE:
740
ADDRESS:836 CAMINO DE LOS MARESTELEPHONE:
(949) 492-5972
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 5DATE:
09/25/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Roy MoellerTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and reviewed and obtained pertinent documentation such as medication orders. Regarding the allegation that staff are mismanaging resident's medication, the investigation revealed the following: Per physician report dated March 28, 2026, Resident 1 (R1) is not allowed to administer own routine and PRN medications nor store own medications. Facility staff indicated storing and administering routine medications for the resident. However, the resident stored and self administered PRN medications and an inhaler as well as had duplicate routine medications in the room. Resident was hospitalized on September 2, 2026 and has not returned to the facility. LPA observed facility stored insulin but was unable to observe any other medications as a friend picked up all the resident's medications once the resident was hospitalized. CONTINUED ON LIC 9099 C DATED 09/25/2026
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
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 3
Control Number 22-AS-20260904165443
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: CALIFORNIA LIFESTYLES II
FACILITY NUMBER: 306003005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2026
Section Cited
CCR
87464(f)(4)
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Basic services shall at a minimum include: Personal assistance and care as needed by the resident.., 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:
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Licensee to conduct an in-service on medication administration and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1 was assisted with medication administration. R1 was storing/ administering PRN medications when physician report prohibits such action which poses a potential health and safety risk to residents in care.
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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: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260904165443
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: CALIFORNIA LIFESTYLES II
FACILITY NUMBER: 306003005
VISIT DATE: 09/25/2026
NARRATIVE
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Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Deficiency is being cited on the attached LIC-9099D.
An exit interview was conducted and a copy of this report as well as the appeal rights were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3