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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005875
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:38:05 AM

Document Has Been Signed on 02/23/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFIC SOLSTICE INTEGRATIVE CLINICFACILITY NUMBER:
306005875
ADMINISTRATOR:DEVEREUX, BRITTENFACILITY TYPE:
775
ADDRESS:26732 CROWN VALLEY PKWY #443TELEPHONE:
(949) 402-9520
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 30CENSUS: 0DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Britten DevereuxTIME COMPLETED:
11:50 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Britten Devereux and discussed the purpose of the inspection. LPA and AD conducted a tour of the inside and outside of the facility, common areas, group rooms, kitchen, and storage areas and observed the following:

During the inspection, LPA observed there were no staff present. LPA observed no residents were present. LPA inspected common areas, group rooms, kitchen, and storage areas and observed they were clean and organized, and found no health and safety issues. LPA observed hallways and walkways were free of obstruction. AD stated that there are 3 programs at this location, 2 of which have been operating since 2020 and 1 of which is licensed by Community Care Licensing but has not yet accepted its first client.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, and communication and emergency plan. LPA requested and reviewed the COVID-19 Mitigation Plan, Infection Control Plan, and Emergency Disaster Plan.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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