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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006100
Report Date: 06/20/2024
Date Signed: 07/31/2024 11:38:16 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
06/13/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240613161112
FACILITY NAME:FIRST LIGHT RECOVERYFACILITY NUMBER:
306006100
ADMINISTRATOR:SIENNA KUEHNISFACILITY TYPE:
772
ADDRESS:27732 PASEO BARONATELEPHONE:
(407) 616-8872
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 2DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Jennifer DevoreTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility does not have a Program Director
INVESTIGATION FINDINGS:
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 This is an amended report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Clinical Director (CD) Jennifer Devore, discussed the purpose of the inspection, and explained the allegation. Licensee (LE) Neal Patel appeared via telephone.

The investigation into the allegation that the facility does not have a Program Director and revealed the following: During the course of the investigation, LPA inspected the facility, interviewed LE and CD, and obtained and reviewed copies of the resident roster, staff roster, and a witness statement dated June 13, 2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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 5
Control Number 22-AS-20240613161112
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: FIRST LIGHT RECOVERY
FACILITY NUMBER: 306006100
VISIT DATE: 06/20/2024
NARRATIVE
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Regarding the allegation that the facility does not have a Program Director: it was alleged that the facility does not have an approved Program Director at the facility and that while the facility had submitted some potential candidates for Program Director, these candidates did not meet DHCS’ minimum requirements. LPA reviewed a witness statement dated June 13, 2024, which corroborated the allegation. LPA interviewed CD and LE who admitted that DHCS has not approved a Program Director for this facility.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This is an amended report
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240613161112
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: FIRST LIGHT RECOVERY
FACILITY NUMBER: 306006100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
00000
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This page was amended due to this first citation being created in error.
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Type B
07/18/2024
Section Cited
CCR
81064.1(a)
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81064.1 Program Director Qualifications and Duties (a) All social rehabilitation facilities shall have a program director. This requirement was not met as evidenced by:
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Licensee stated they will appoint a Program Director that meets DHCS’ requirements and submit proof to LPA by POC due date.
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Based on interviews, the licensee did not ensure the facility had a Program Director approved by DHCS, which poses a potential safety risk to persons 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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/13/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240613161112

FACILITY NAME:FIRST LIGHT RECOVERYFACILITY NUMBER:
306006100
ADMINISTRATOR:SIENNA KUEHNISFACILITY TYPE:
772
ADDRESS:27732 PASEO BARONATELEPHONE:
(407) 616-8872
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 2DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Jennifer DevoreTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility does not have an approved program certification from the Department of Health Care Services (DHCS).
Facility did not answer telephone calls promptly and completely.
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
11
12
13
 This is an amended report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Clinical Director (CD) Jennifer Devore, discussed the purpose of the inspection, and explained the allegations. Licensee (LE) Neal Patel appeared via telephone.

The investigation into the allegations that the facility does not have an approved program certification from the Department of Health Care Services (DHCS) and the facility did not answer telephone calls promptly and completely revealed the following: During the course of the investigation, LPA inspected the facility, interviewed LE and CD, and obtained and reviewed copies of the resident roster, staff roster, a witness statement dated June 13, 2024, and the facility’s DHCS Certification dated May 18, 2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240613161112
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: FIRST LIGHT RECOVERY
FACILITY NUMBER: 306006100
VISIT DATE: 06/20/2024
NARRATIVE
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Regarding the allegation that the facility does not have an approved program certification from the Department of Health Care Services (DHCS): it was alleged that the facility’s certification expired May 18, 2024, the facility was advised it would not be issued a new certification until it had an approved Program Director at the facility, and the facility had submitted some potential candidates for Program Director that did not meet DHCS’ minimum requirements. LPA reviewed the facility’s DHCS Certification dated May 18, 2023, which indicates an expiration date of May 18, 2024. LPA reviewed a witness statement dated June 13, 2024, which corroborates that the certification is expired. LPA interviewed CD and LE who admitted that DHCS did not issue a new certification because DHCS had not yet approved a new Program Director for this facility. However, while the certification is expired, the information obtained revealed that the facility is going through the plan of correction process with DHCS and is working towards compliance and that the facility is still considered to be actively certified by DHCS. The information obtained did not corroborate the allegation.

Regarding the allegation that the facility did not answer telephone calls promptly and completely: it was alleged that the facility has not been in contact with DHCS since the expiration of their certification on May 18, 2024, and DHCS emailed and left voicemails for facility representatives but has not been able to make contact with facility representatives. LPA reviewed a witness statement dated June 13, 2024, which corroborated the allegation. LPA interviewed CD who could not provide information regarding this allegation. LPA interviewed LE who denied the allegation, stating LE and other facility staff were very responsive to DHCS staff and responded to phone calls and emails to the best of their ability. The information obtained is conflicting.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This is an amended report
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5