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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005396
Report Date: 10/25/2025
Date Signed: 10/25/2025 10:34:38 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
11/07/2024 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241107142511
FACILITY NAME:PACE RECOVERY CENTER LLCFACILITY NUMBER:
306005396
ADMINISTRATOR:WILLIAM SANCHEZFACILITY TYPE:
772
ADDRESS:211 22ND STTELEPHONE:
(213) 924-6442
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:6CENSUS: 4DATE:
10/25/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Bryan JohnsonTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Clients' Needs and Services Plans are not complete
Staff do not meet minimum qualifications
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 deliver findings on 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 and clients as well as reviewed and obtained pertinent documentation such as staff training. Regarding the allegations that clients' Needs and Services Plans are not complete and staff do not meet minimum qualifications, the investigation revealed the following: Needs and Services plans for C1 and C2 are missing information on the Needs and Services plans including documentation for medical services and recommended services for C1 and medical conditions and nutrition for C2. Seven out of seven staff training records reviewed are missing required training topics per Licensing regulations. Based on record review, the preponderance of evidence standard has been met, therefore the allegations are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report along with appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2025
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 4
Control Number 22-AS-20241107142511
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: PACE RECOVERY CENTER LLC
FACILITY NUMBER: 306005396
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2025
Section Cited
CCR
81068.2(b)91)
1
2
3
4
5
6
7
For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission, that must include: A written assessment as required in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Section 532.2(b). This req is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to audit needs and services plan and forward proof of audit by POC due date.
8
9
10
11
12
13
14
Based on record review, Licensee failed to ensure the assessment was complete for C1 and 2. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
11/08/2025
Section Cited
CCR
81065(f)
1
2
3
4
5
6
7
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This req is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to forward proof of training to LPA by POC due date.
8
9
10
11
12
13
14
based on record review, Licensee failed to ensure staff were provided required training. This poses a potential health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/07/2024 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241107142511

FACILITY NAME:PACE RECOVERY CENTER LLCFACILITY NUMBER:
306005396
ADMINISTRATOR:WILLIAM SANCHEZFACILITY TYPE:
772
ADDRESS:211 22ND STTELEPHONE:
(213) 924-6442
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:6CENSUS: 4DATE:
10/25/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Bryan JohnsonTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not document staff hours actually worked
Program Director is not on premises the number of hours necessary
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 deliver findings on 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 and clients, Regarding the allegations that Facility did not document staff hours actually worked and Program Director is not on premises the number of hours necessary, the investigation revealed the following: Per licensing regulations, facility is not required to document staff hours actually worked. However, LPA reviewed staff schedule and LIC 500 which showed two staff on shift for each schedule as outlined in facility program plan. Three out of three staff and one out of one client confirm Program Administrators are on site daily. Based on interviews conducted and record review, 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 the evidence to prove that the alleged violations occurred.
Exit interview conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2025
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 4