Inspection Reports for Raya‘s Paradise San Clemente
101 Avenida Calafia, San Clemente, CA 92672, United States, CA, 92672
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, safe, and compliant in earlier reports. However, several complaint investigations between July and August 2025 identified issues mainly related to medication management and resident rights, including unsecured medications, improper medication destruction, failure to report a missing Morphine incident, and failure to safeguard a resident’s personal property. Some investigations substantiated immediate health and safety risks, such as staff serving as a resident’s power of attorney without consent and inadequate supervision allowing a resident to leave unassisted. The facility addressed earlier deficiencies related to staff training and administrator qualifications by August 6, 2025. The most recent report from October 23, 2025, had no deficiencies and found an allegation about medical neglect to be unfounded, indicating some improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
41% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 33
Capacity: 80
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that facility staff did not seek medical attention for a resident.
Complaint Details
The allegation that facility staff did not seek medical attention for a resident was investigated and deemed unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the allegation was unfounded. Documentation and interviews confirmed the resident was receiving appropriate wound care and repositioning as directed by hospice.
Report Facts
Complaint Control Number: 22-AS-20251017151548
Capacity: 80
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Monica Westphaln | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Census: 29
Capacity: 80
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
An unannounced case management visit was conducted to deliver an amended report for a previously issued complaint.
Complaint Details
The visit was related to complaint #22-AS-20250228162254. No substantiation status is provided in the report.
Findings
The Licensing Program Analyst delivered an amended report related to complaint #22-AS-20250228162254 initially delivered on 07/01/2025. An exit interview was conducted and a copy of the report was left at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended report. |
| Monica Westphaln | Administrator/Director | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Census: 27
Capacity: 80
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced case management visit to the facility to deliver complaint reports that had a date glitch when delivered on 08/14/2025.
Findings
The visit involved delivering corrected complaint investigation reports with updated dates. An exit interview was conducted and a copy of the report was left at the facility.
Inspection Report
Complaint Investigation
Census: 27
Capacity: 80
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not ensure medications were safely secured for residents in care and that a resident developed pressure injuries while in care.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure medications were safely secured and that a resident developed pressure injuries. The medication security allegation was substantiated, while the pressure injury allegation was unsubstantiated.
Findings
The allegation regarding pressure injuries was unsubstantiated due to lack of evidence. The allegation that medications were not safely secured was substantiated; a resident's Morphine Sulfate was inadvertently given to another resident's family, posing an immediate health and safety risk. Staff responsible was terminated and a plan of correction was required.
Deficiencies (1)
Failure to keep centrally stored medications in a safe and locked place accessible only to responsible employees, evidenced by Morphine Sulfate being inadvertently given to another resident's family.
Report Facts
Capacity: 80
Census: 27
Plan of Correction Due Date: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monica Westphaln | Administrator | Facility administrator involved in exit interview and receipt of report |
| Staff 1 | Terminated staff responsible for medication error |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 80
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation regarding a missing Morphine incident reported in October 2024.
Complaint Details
The visit was complaint-related, investigating an incident of missing Morphine in October 2024 which was not reported to the department.
Findings
The licensee failed to report the incident involving missing Morphine to the department, posing a potential health and safety risk to residents in care.
Deficiencies (1)
Licensee failed to ensure incident regarding missing Morphine in October 2024 was reported to the department.
Report Facts
Capacity: 80
Census: 28
Plan of Correction Due Date: Aug 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Monica Westphaln | Administrator/Director | Facility representative during the inspection |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 80
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff were inappropriately disposing of residents' medication and not administering residents' medication resulting in residents becoming violent.
Complaint Details
The complaint investigation was substantiated regarding inappropriate medication disposal practices, with the allegation deemed substantiated. The allegation that staff were not administering medication resulting in resident violence was deemed unfounded.
Findings
The investigation substantiated that medication destruction was occurring without the required witness signatures, posing a potential health and safety risk. Another allegation that staff were not administering residents' medication resulting in violence was found to be unfounded based on medication administration records and resident progress notes.
Deficiencies (1)
Failure to ensure medication destruction is occurring with facility administrator and another adult including two signatures as required by regulation.
Report Facts
Capacity: 80
Census: 27
Deficiencies cited: 1
Plan of Correction Due Date: Aug 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monica Westphaln | Administrator | Facility administrator involved in the investigation |
Inspection Report
Plan of Correction
Census: 27
Capacity: 80
Deficiencies: 3
Date: Aug 6, 2025
Visit Reason
Unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 2025-07-24.
Findings
All previously cited deficiencies related to Postural Supports, Administrator Qualifications, and First Aid Training have been cleared and the licensee has complied with the Plan of Correction.
Deficiencies (3)
Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to Postural Supports
Deficiency cited under Title 22 Regulation 87405(a) pertaining to Administrator Qualifications
Deficiency cited under Title 22 Regulation 87411(c)(1) pertaining to First Aid Training
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit |
| Monica Westphaln | Administrator/Director | Facility representative met during the inspection |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 80
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including staff not safeguarding residents' personal items, resident needs not being met, medication mismanagement, facility cleanliness, and uncomfortable accommodations.
Complaint Details
The complaint investigation was substantiated regarding staff not safeguarding residents' personal items, specifically a ring that was cut off a resident's finger and not compensated to the family. Other allegations about resident care, medication management, facility cleanliness, and accommodations were unsubstantiated.
Findings
The investigation substantiated the allegation that staff failed to safeguard a resident's ring, which had to be cut off and was not compensated to the family, posing a health and safety risk. Other allegations regarding resident needs, medication management, cleanliness, and accommodations were found unsubstantiated based on interviews, observations, and documentation.
Deficiencies (1)
Failure to safeguard residents' cash resources, personal property and valuables entrusted to staff, including failure to compensate for a damaged ring.
Report Facts
Facility census: 27
Total capacity: 80
Deficiency count: 1
Plan of Correction due date: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monica Westphaln | Administrator | Facility administrator involved in exit interviews and referenced in findings |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 80
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation regarding the facility's failure to issue a timely refund to a resident's family after the resident's death.
Complaint Details
The visit was triggered by a complaint regarding the delayed refund to R1's family, which was not received until 06/06/2025 despite the resident's belongings being removed on 04/21/2025. The complaint was substantiated by record review.
Findings
The facility was found to have violated California Code of Regulations by failing to ensure a refund was paid to the resident's family within 15 days after the resident's belongings were removed, posing a potential health and safety risk.
Deficiencies (1)
Failure to issue a refund to the resident's estate within 15 days after the resident's personal property was removed from the facility.
Report Facts
Census: 27
Total Capacity: 80
Plan of Correction Due Date: Aug 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Monica Westphaln | Administrator/Director | Facility representative during the inspection and recipient of the report |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 29
Capacity: 80
Deficiencies: 3
Date: Jul 24, 2025
Visit Reason
The visit was an unannounced annual required inspection to evaluate compliance with licensing requirements at Raya's Paradise of San Clemente.
Findings
The facility was generally clean, safe, and sanitary with adequate supplies and functioning equipment. However, deficiencies were cited including lack of physician orders for bed rails for one resident, absence of a designated backup administrator, and three staff members lacking first aid training.
Deficiencies (3)
One out of four residents (R8) had bed rails without physician orders, posing an immediate health, safety, or personal rights risk.
No updated LIC 308 designating a backup administrator; facility did not have a backup administrator during the visit, posing a potential health, safety, or personal rights risk.
Three out of eight staff (S1-3) lacked first aid training, posing a potential health, safety, or personal rights risk.
Report Facts
Residents on hospice care: 2
Residents with bed rails observed: 4
Staff without first aid training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Westphaln | Administrator | Named as facility administrator with valid certificate. |
| Vladimir Estrin | Third party vendor | Met with licensing staff to provide documents; no fingerprint clearance found. |
| Kelly Brady | Facility representative | Participated in exit interview and received report. |
| Alisa Ortiz | Licensing Program Manager | Conducted the inspection. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection and signed report. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 80
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was denied visitors at the facility.
Complaint Details
The allegation that a resident was denied visitors was investigated and found unsubstantiated after interviews with staff, residents, and witnesses.
Findings
The investigation found conflicting witness statements regarding visitation denial, with no specific dates or times verified. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 22-AS-20250318170616
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 80
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-03-06 regarding staff failing to prevent a resident from leaving the facility unassisted.
Complaint Details
The complaint alleged that staff did not prevent a resident from leaving the facility unassisted. The allegation was substantiated based on interviews, witness statements, and physician report indicating the resident's diagnosis of Dementia and inability to leave unassisted.
Findings
The investigation substantiated that staff failed to provide adequate care and supervision, as Resident 1 left the facility unattended to travel to another community, posing an immediate health and safety risk.
Deficiencies (1)
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 failure to ensure Resident 1 was provided care and supervision, who left the facility unattended to travel to another community, posing an immediate health and safety risk.
Report Facts
Capacity: 80
Census: 30
Plan of Correction Due Date: Jul 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Andrea Mendivil | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Monica Westphaln | Administrator | Facility administrator met with investigators during the visit |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 80
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 2025-03-03 regarding staff serving as a resident’s agent under a power of attorney.
Complaint Details
The complaint alleging staff served as resident’s agent under a power of attorney was substantiated based on record review and interviews. The facility administrator was found to be designated as the resident's power of attorney with a back-up designee, which was not requested by the resident.
Findings
The investigation substantiated that the facility administrator was designated as the healthcare power of attorney for a resident, with a back-up designee and prospective conservator, which was not requested by the resident. This designation violated regulations and posed an immediate health and safety risk.
Deficiencies (1)
Licensee failed to ensure an employee of the facility was not designated as a power of attorney for Resident 1, posing an immediate health and safety risk.
Report Facts
Capacity: 80
Census: 30
Deficiency Type: 1
Plan of Correction Due Date: Jun 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Westphaln | Facility Administrator | Named in finding as designated healthcare power of attorney for resident |
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 80
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident being blocked from speaking with family via telephone and the facility allowing a resident to mix alcohol with medications.
Complaint Details
The complaint investigation was substantiated regarding the removal of the resident's phone and blocking of family member's number, violating personal rights. The allegation that the facility allowed mixing alcohol with medications was unsubstantiated.
Findings
The investigation substantiated that facility staff unnecessarily removed a resident's personal cell phone and blocked a family member's number, violating the resident's rights to confidential calls. Another allegation that the facility allowed a resident to mix alcohol with medications was unsubstantiated based on interviews and record review.
Deficiencies (1)
Failure to provide reasonable access to telephones to make and receive confidential calls, including removal of resident's phone and blocking of family member's number.
Report Facts
Capacity: 80
Census: 30
Deficiencies cited: 1
Plan of Correction Due Date: Jul 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monica Westphaln | Administrator | Facility administrator involved in the investigation and exit interview |
| Andrea Mendivil | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Census: 40
Capacity: 80
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
An unannounced health and safety visit was conducted as a case management health check to assess the facility's compliance and resident well-being.
Findings
The facility was toured and residents were interviewed; residents appeared clean, well cared for, and expressed satisfaction with the care. No health or safety concerns were noted during the visit.
Inspection Report
Annual Inspection
Census: 37
Capacity: 80
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
The visit was an unannounced annual required inspection to evaluate compliance with licensing regulations at Raya's Paradise of San Clemente.
Findings
The facility was found to be clean, safe, and sanitary with no citations issued. Resident and staff files contained required documentation, medications were properly stored and administered, and safety equipment was operational and up to date.
Report Facts
Hospice residents: 4
Fire drill date: Jul 16, 2024
Smoke and CO detector inspection date: Jul 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Westphaln | Administrator / Chief Operating Officer / Executive Director | Facility administrator with valid certificate; participated in facility tour |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Gilbert Buenrostro | Maintenance Director | Participated in facility tour during inspection |
Inspection Report
Original Licensing
Capacity: 80
Deficiencies: 0
Date: Mar 30, 2022
Visit Reason
Initial licensing evaluation of a Residential Care Facility for the Elderly to verify applicant and administrator understanding of California Code Title 22 regulations and readiness for licensing.
Findings
The applicant and administrator participated in a telephone interview confirming their understanding of facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Westphaln | Administrator | Applicant/administrator participating in licensing evaluation and interview. |
| Moti Gamburd | Participant in licensing evaluation interview. | |
| Jude De La Concepcion | Licensing Program Manager | Named in report header. |
| Bethany Hunter | Licensing Program Analyst | Named in report header and signed report. |
Report
March 18, 2026
Report
March 18, 2026
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March 5, 2026
Report
January 15, 2026
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December 23, 2025
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December 23, 2025
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December 23, 2025
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November 19, 2025
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November 6, 2025
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November 6, 2025
Report
August 14, 2025
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August 6, 2025
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July 1, 2025
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July 1, 2025
Report
July 15, 2022
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