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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005879
Report Date: 04/12/2022
Date Signed: 04/18/2022 12:36:46 PM

Document Has Been Signed on 04/18/2022 12:36 PM - 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: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: 2DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Chad Chapman, Cindy StillmanTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Jessica Cho and Celine DePerio made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry after completing the COVID-19 screening procedures with Mental Health Tech Trainer, Cynthia Stillman. Administrator (AD) Michael Villarreal arrived on site at 9:36 AM and Melissa Wright arrived approximately at 9:55 AM. The facility is a single-story home with 4 bedrooms, 3 full bathrooms and with a therapy room, office, living room, kitchen, dining room, and a 2-car garage. Facility is licensed for 6 ambulatory clients. As of today, there are 2 clients in care and 10 staff members rotating on duty. Upon arrival, LPAs did not observe the required Coronavirus 2019 (COVID-19) precautionary signs at the front door and entry way. LPAs and licensee toured the interior and exterior of the facility at 9:35 AM and observed the following:

During the facility tour, LPAs did not observe any hazards in the interior and the backyard of the facility. LPAs observed the screen door by the living room had a tear on the bottom right. LPAs reviewed and inspected the FIrst Aid Kit and observed no First Aid Manual. The auditory exit alarms and smoke/carbon monoxide detectors tested operational. The fire extinguishers were charged. LPAs observed medications and sharp objects locked in the office closet. A two day perishable and a seven day non-perishable food items were observed. The stove was lighted unassisted. LPAs inspected the garage which the door was unlocked and additional food, water, emergency supplies, and cleaning solutions were observed. The washer and dryer were in the garage. The cleaning supplies/solutions and PPE were locked in the closet by the entryway. LPAs did not observe a 30-day supply of PPE and did not observe the PUB475 See Something, Say Something Poster in the facility. Common areas were clean and clear of hazards and doorways were free of obstructions.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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Document Has Been Signed on 04/18/2022 12:36 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/12/2022 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81065(I)(2)

Request of transfer of a criminal record clearance as specified in section 810019 (f) or
Deficient Practice Statement
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This requirement is not met as evidenced by: LPAs reviewed 4 staff records. The facility did not request a transfer of the criminal record request as required for two out of the five staff. This poses an immediate health and safety risks to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee agrees to associate Staff 1 and Staff 3 to the faclity and to forward proof to LPA by POC due date.
Type A
Section Cited
CCR
81065(I)(1)

Obtain a California Clearance or a Criminal Records Exemption as required by law or Department regulations or
Deficient Practice Statement
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This requirement is not met as evidenced by: LPAs reviewed 4 staff records. The facility did not obtain a California Clearance or a Criminal Records Exemption as required by law or Department regulations for one out of the four staff. This poses an immediate health and safety risks to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee agrees to obtain a California Clearance or a Criminal Records Exemption for Staff 2 to the facility and to forward proof to LPA by POC date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER, LLC
FACILITY NUMBER: 306005879
VISIT DATE: 04/12/2022
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There are a total of 4 client bedrooms and two out of the four bedrooms are shared. All bedrooms were clean and organized and had the required furnishings, linens, and storage space. Hot water in Bathroom #1 measured 125.9 degrees Fahrenheit, Bathroom #2 measured at 125.2 degrees Fahrenheit, Bathroom #3 measured at 130.4 degrees Fahrenheit. For the exterior portion, the grounds were toured and no bodies of water were observed. The backyard had the required furniture and a covered patio with a place to sit under sufficient shading. The side gates were self-latching and operational. Facility has an approved mitigation plan.

LPA reviewed the background clearances and associations of all staff members and one out of 10 staff members did not have a background clearance and two of out 10 staff members were not associated to the facility.

Based on the observations made during today's visit, deficiencies are being sited per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and the LPA will follow-up with the corrections. An exit interview was conducted with the facility representative and a copy of the report was provided as well as a copy of appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8

Created By: Jessica Cho On 04/12/2022 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(l)

The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inacessible to clients.
Deficient Practice Statement
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This requirement is not met as evidenced by: LPA opened the garage door which was unlocked and observed laundry detergents and sanitizing wipes are stored in an area that is accessible to clients. This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee agrees to keep the garage door locked at all times. This was corrected during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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