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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006584
Report Date: 10/09/2026
Date Signed: 10/09/2026 02:19:45 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
10/07/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20261007080425
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: DATE:
10/09/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Dyan SummerellTIME COMPLETED:
02:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled a resident roughly
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. 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 as well as reviewed and obtained pertinent documentation such as termination paperwork. Regarding the allegations that staff did not follow reporting requirements and staff handled a resident roughly, the investigation revealed the following: Facility is required to report incidents to the department within seven days of the incident occurring. Facility provided a copy of the incident report to LPA on 10/01/2026. The incident report dated 09/19/2026 indicated that Staff 1 had slapped Resident 1's (R1) leg after the resident had kicked the staff. On 06/24/2026 it was reported by staff that S1 had been rough with a resident. S1 was counseled by management on appropriate behavior. A further investigation ensued in August 2026 and five out of seven staff interviewed stated that S1 had been inappropriate or rough with residents. CONTINUED ON LIC 9099C DATED 10/09/2026
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
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-20261007080425
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: 10/09/2026
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
26
27
28
29
30
31
32
The staff was put on suspension and received return to work coaching and plan which included the staff being moved from memory care to the assisted living and being shadowed by other staff. On 09/19/2026, S1 was observed "Lightly slapping" R1 after the resident had kicked the staff in the breast while assisting the resident for bed. The resident was assessed to have no injuries from the incident. S1 acknowledged the incident and was terminated effective 10/01/2026.
Based on interviews conducted and record review, the allegations are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and violations have 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: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20261007080425
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: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2026
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to conduct an in-service on personal rights and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to ensure R1 was treated with respect. S1 slapped the resident after being kicked by the resident which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
10/23/2026
Section Cited
CCR
87211(a)(1)(D)
1
2
3
4
5
6
7
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency.. This report shall include the resident's name..Any incident which threatens the welfare, safety or health of any resident...This req is not met:
1
2
3
4
5
6
7
Licensee to review the regulation and forward a statement of understanding to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review, Licensee failed to submit an incident report within seven days of the incident which poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3