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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005879
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:04:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
10/15/2025 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20251015085141
FACILITY NAME:SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLCFACILITY NUMBER:
306005879
ADMINISTRATOR:VILLARREAL, MICHAELFACILITY TYPE:
772
ADDRESS:24372 AUGUSTIN STTELEPHONE:
(949) 533-3046
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Andrew Crawford and Gabrielle HilgerTIME COMPLETED:
03:18 PM
ALLEGATION(S):
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- Facility is not meeting staffing needs
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. LPA spoke to Administrator (AD) Michael Villarreal over the phone and explained the reason for the visit.

The department received a complaint on October 15, 2025 and LPA Tea conducted the initial 10 day visit on October 23, 2025. It was alleged that the facility is not meeting staffing needs. LPA Tea interviewed facility staff and clients and collected pertinent documents such as staff and client rosters, staff scheduling. The investigation determined the following:

Per interviews with the staff the facility is struggling with staffing issues. Recently at the facility there have been terminations, resignations that were short notice, and staff calling out at the last minute. Three of
(Complaint Investigation Report continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 3
Control Number 22-AS-20251015085141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLC
FACILITY NUMBER: 306005879
VISIT DATE: 10/23/2025
NARRATIVE
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four staff have confirmed that the facility is currently hiring new staff to cope with the staffing issues. To fill in the gaps staff have had to do double shifts and some managing staff have had to step in to ensure there is enough staffing for the facility. The staff deals with clients who have various mental health issues, like anxiety, bipolar disorder, depression, PTSD, schizophrenia, and suicide, in which if a crisis incident occurs there needs to be at least two staff present. Per Title 22, California Code Regulations, Day Staff Ratio CCR 81065.5 (a)(2) states that Short Term Crisis Residential Programs shall have at least two direct care staff on duty on the premises any time clients are present at the facility.

LPA spoke to clients regarding the services provided. They really enjoy their treatment here and have learned a lot while at the facility. Two out of two clients confirmed that there is a shortage of staff at the facility. At various times there would be one mental health technician in the early morning and in the evening.

LPA received and review documents, such as staff scheduling that shows there were at least a few shifts that showed there was one Mental Health Technician staff during a shift, such as September 28, 2025, September 29, September 30, October 1, October 2, October 3, October 4 and so forth. LPA also received time sheet documents for the month of September of staff clocking in and out for their shifts, which shows there was one staff at various shifts during the day.

Therefore, based on LPA Tea's observations and interviews conducted, the allegation that the facility is not meeting staffing needs is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following are being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with Director of Operations Gabrielle Hilger, and Administrator Michael Villarreal on the phone and a copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251015085141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLC
FACILITY NUMBER: 306005879
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
CCR
81065.5(a)(2)
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Day Staff-Client Ratio ... Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility. This requirement was not met as evidence by:
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Facility to read regulation and sign a statement of understanding which all upper management needs to sign. Facility will email a detailed plan of action of what are they doing to deal with insufficient staffing and updated staff schedule with two staff listed per shift. Facility will email LPA by POC due date by COB.
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Based on LPA's investigation, interviews conducted and review of documents there is a staff shortage. Various shifts on staff scheduling shows that there is one staff present. This poses an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
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