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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006100
Report Date: 05/13/2025
Date Signed: 05/13/2025 12:38:57 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
05/05/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250505141550
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: 5DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Jennifer DevoreTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Direct care staff does not meet the minimum requirements to work at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Program Director Jennifer Devore and explained the reason for the visit. LPA and the Program Director toured the facility. The investigation into the allegation revealed the following. It was alleged that the direct care staff did not have one year experience working with clients or If the employee does not have the required experience, the program shall document a specific plan of supervision and in-service training for the employee which will guarantee the ongoing qualification of the employee to perform the job. LPA reviewed 13 staff files. Staff 1 did not have the required one year experience and did not have a documented plan of supervision on file. The preponderance of evidence standard has been met, therefore the allegation has been substantiated. Deficiencies are cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 2
Control Number 22-AS-20250505141550
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: FIRST LIGHT RECOVERY
FACILITY NUMBER: 306006100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
81065(n)
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All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i). This requirement was not met as evidenced by...
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Licensee agrees to complete a plan of supervision for Staff 1 that meets the regulatory requirement of CCR 81065(n). Licensee to submit to the LPA proof of correction by the POC due date.
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A review of staff files show that the licensee did not meet this requirement in 1 out of 13 staff members which poses a potential 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2