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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 10/01/2026
Date Signed: 10/01/2026 03:47:42 PM

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
07/15/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260715092753
FACILITY NAME:SEVILLE OF SAN CLEMENTE, THEFACILITY NUMBER:
306006584
ADMINISTRATOR:SUMMERELL, DYANFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:130CENSUS: 75DATE:
10/01/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Wynona DetuyatoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Residents’ needs are not being met in a timely manner due to lack of staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into 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 toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as pendant call history. Regarding the allegation that Residents’ needs are not being met in a timely manner due to lack of staffing, the investigation revealed the following: Per staff schedule, staffing is two caregivers/ one med tech for 1st shift, two caregivers and a float with med tech on 2nd shift and one caregiver and a float as well as a med tech on the overnight shift. LPA reviewed the pendant call history for 07/09-07/14/2026 and observed six response times between 24 minutes and 55 minutes. Two out of two caregivers state the issues with staffing have gotten better but still struggle at times. Three out of three residents and witness state occasional long wait times for assistance.
CONTINUED ON LIC 9099C DATED 10/01/2026
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
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 7
Control Number 22-AS-20260715092753
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 10/01/2026
NARRATIVE
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Based on interviews conducted and record review, the allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.
An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
07/15/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260715092753

FACILITY NAME:SEVILLE OF SAN CLEMENTE, THEFACILITY NUMBER:
306006584
ADMINISTRATOR:SUMMERELL, DYANFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE:CAZIP CODE:
92673
CAPACITY:130CENSUS: 75DATE:
10/01/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Wynona DetuyatoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not answer facility phone
Staff did not provide residents’ medication(s) as prescribed
Staff did not ensure medication records
Staff did not adequately provide care/supervision resulting in resident falling
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into 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 toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegations that Staff do not answer facility phone, Staff did not provide residents’ medication(s) as prescribed, Staff did not ensure medication records and Staff did not adequately provide care/supervision resulting in resident falling, the investigation revealed the following: Four out of four staff state that phone calls at night are forwarded to the med tech and then onto management should there be no answer. LPA called the facility and staff answered the phone. LPA reviewed medication administration record (MAR) for Resident 1 (R1) for February-June 2026 and observed the order for Paroxetine (Generic for Paxil) on the MAR as well as documentation of administration. CONTINUED ON LIC 9099C DATED 10/01/2026
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20260715092753
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 10/01/2026
NARRATIVE
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Three out of three staff state R1 was a two-person assist. All three deny the resident had a fall. Per facility notes, R1 started to slide during a transfer from recliner to wheelchair and the caregivers assisted the resident to the floor. The resident was noted to have no injuries and responsible party was notified.

Based on record review and observation, LPA is unable to corroborate the allegations.
Therefore, the allegations are deemed UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.
An exit interview was conducted and a copy of this report this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20260715092753
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2026
Section Cited
CCR
87464(f)(1)
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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 req is not met as evidenced by:
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Licensee to provide detailed written plan on how to address staffing issues with responding to pendant pulls and forward proof to LPA by POC due date.
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Based on record review and interviews conducted, Licensee failed to ensure facility is staffed appropriately to respond timely to pendant calls which poses an immediate 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: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
07/15/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260715092753

FACILITY NAME:SEVILLE OF SAN CLEMENTE, THEFACILITY NUMBER:
306006584
ADMINISTRATOR:SUMMERELL, DYANFACILITY TYPE:
740
ADDRESS:2421 CALLE FRONTERATELEPHONE:
(760) 382-3463
CITY:SAN CLEMENTESTATE:CAZIP CODE:
92673
CAPACITY:130CENSUS: 75DATE:
10/01/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Wynona DetuyatoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff did not assist with ensuring home health nursing and physical/occupational therapy occurred timely
Staff are not properly trained to transfer residents
Staff did not communicate with residents authorize representative
INVESTIGATION FINDINGS:
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2
3
4
5
6
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into 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 toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staff training. Regarding the allegations that Staff did not assist with ensuring home health nursing and physical/occupational therapy occurred timely, Staff are not properly trained to transfer residents, and Staff did not communicate with residents authorized representative, the investigation revealed the following: Select Rehab offers physical and occupational therapy at the facility. R1's responsible party indicated difficulty with the onboarding process at Select Rehab. Select Rehab is a third party agency not overseen by department regulations. During the visit, LPA reviewed staff training records and observed staff received transfer training by Newport Hospice on 01/28/2026 and Hoag at Home on 04/09/2026. Interview with responsible party confirmed that the facility was communicating with the responsible party on an ongoing basis.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
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 7
Control Number 22-AS-20260715092753
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: SEVILLE OF SAN CLEMENTE, THE
FACILITY NUMBER: 306006584
VISIT DATE: 10/01/2026
NARRATIVE
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Based on interviews conducted and record review, the allegations are deemed unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis.

An exit interview was conducted, and a copy of the report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7