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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005892
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:15:48 PM

Document Has Been Signed on 01/12/2023 01:15 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:FIRST LIGHT RECOVERY LLCFACILITY NUMBER:
306005892
ADMINISTRATOR:DEVORE, JENNIFERFACILITY TYPE:
772
ADDRESS:31211 CASA GRANDE DRIVETELEPHONE:
(407) 616-8872
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 5DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Jennifer DevoreTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Administrator Jennifer Devore. LPA explained the reason for the visit. During the investigation into complaint 22-AS-20230103094625, it was discovered that Staff 1 (S1) is not background cleared. S1 was working at the facility when the LPA arrived. A review of records showed S1 is not background cleared. LPA informed the Administrator that S1 cannot be present at the facility until they are background cleared and properly associated to the facility. Administrator stated she understood. LPA witnessed S1 leave the facility. Based on the observations made during today's visit, a deficiency is being sited per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An immediate CIVIL PENALTY (LIC421BG) is assessed.

An exit interview was conducted with the Administrator and a copy of this report was provided along with the appeal rights.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 01:15 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/12/2023 at 12:45 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: FIRST LIGHT RECOVERY LLC
FACILITY NUMBER: 306005892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
81019(e)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department...
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Administrator agrees to have all staff background cleared prior to them working at the facility. Administrator will train lead staff to ensure all staff are background cleared prior to working at the facility. Proof of training to be submitted to LPA by POC due date.
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This requirement was not met as evidenced by, through a record review and observation, LPA observed S1 was not background cleared and was working at the facility. This poses an immediate Health and Safety risk to clients in care. CIVIL PENALTY ASSESSED.
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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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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