306006100-4-14-2022-22-AS-JALE-CDGQD2-20220414120400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006100
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:04:10 PM

Document Has Been Signed on 04/14/2022 12:04 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		FACILITY NUMBER:	306006100
ADMINISTRATOR:	MORRIS-HERNANDEZ, ERIN		FACILITY TYPE:	772
ADDRESS:	27732 PASEO BARONA		TELEPHONE:	(407) 616-8872
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 6		CENSUS: 0	DATE:	04/14/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Erin Morris-Hernandez		TIME COMPLETED:	12:22 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Administrator Erin Morris-Hernandez. An application to operate a Social Rehabilitation Facility for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was submitted to CCL on 11/02/2021. Average client stay will be 30 days. Structure: The facility is a two story home with 3 client bedrooms (all client bedrooms are shared), living room with a screened fireplace, dining room, family room with a screened fireplace, kitchen, laundry room, 3 car garage and 4 bathrooms, small room used for the medication office and one room used as the staff office and a large activity room on the second floor. Facility telephone phone number is. 949-312-2615. LPA did not observed the See Something, Say Something poster (PUB 475) in the facility. LPA observed there is no door alarm on the front door. There is a back yard with 2 exit gates, one is on the side of the house and the other one is in the center of the backyard fence at the back of property. Both exit gates are not alarmed. There is a shaded seating area in the backyard. LPA observed a stack of roofing tiles next to the side exit gate. Client Bedrooms The client’s bedroom are spacious and will easily accommodate the resident’s belongings. All client bedrooms had the required furnishings. LPA observed the ceiling fan in bedroom number 2 which is upstairs is missing 2 light bulbs. The ceiling is otherwise operational. Signal system There is no signal system.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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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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: FIRST LIGHT RECOVERY	FACILITY NUMBER: 306006100
	VISIT DATE: 04/14/2022

NARRATIVE

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Bedrooms Staff:
No staff will be living at the facility. One room on the second floor will be used as a staff office and the small room adjacent will be used as the medication room and will be kept locked, it will be used to store medication and sharp objects.

Bathrooms:
All bathrooms have working plumbing except the master bathroom. Hot water measured 119.6 degrees Fahrenheit in bathroom 1 which is a powder room on the first floor. Hot water measured 126.8 degrees Fahrenheit in bathroom 2 which is in the master bedroom on the first floor. How water measured 126.1 in bathroom number 3 on the second floor and 126.3 in bathroom 4 which is in the activity room on the second floor. The toilet in the master bathroom did not flush properly.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway storage upstairs.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week. Emergency food and water supply is stored in a cupboard next to the living room.

Food Service:
Facility has no food supply on hand other than the emergency food supply. Facility will have a 2 day perishable, 7 day non-perishable food supply on hand prior to accepting clients.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Five burner gas stove, 1 oven, 1 microwave oven, 1 refrigerator, dish washer, washer, and dryer are clean and operational.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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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: FIRST LIGHT RECOVERY	FACILITY NUMBER: 306006100
	VISIT DATE: 04/14/2022

NARRATIVE

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Toxins:
Any and all toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the supply closet on the first floor.

Medications, First-Aid Kit & Book:
Medication will be stored in the locked medication office on the second floor. First aid kits are stored in the staff office upstairs and downstairs in the living room. The first aid kits have all the required elements.

Resident & Staff Files:
Records will be kept locked in the staff office.

Pool/Jacuzzi & Pets:
No bodies of water in the facility. No pets will be at the facility.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client’s use, stored in the activity room.

Fire clearance:
Was approved by fire inspector Francisco Martinez of the Orange County Fire Authority on 12/23/2021.

Component III:
Is waived, applicant is operating another licensed facility.

The following items must be corrected prior to licensure.

The water temperature must be adjusted to measure between 105.0 to 120.0 degrees Fahrenheit. The roofing tiles stacked next to the front exit gate must be removed or made inaccessible to clients, the PUB 475 poster, See Something Say Something must be posted by the entrance of the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: FIRST LIGHT RECOVERY	FACILITY NUMBER: 306006100
	VISIT DATE: 04/14/2022

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Front and rear exit gates and the front door must be alarmed to notify staff when someone exits. The front exit gate must also be self closing. The toilet in the master bathroom downstairs must be repaired or replaced. The ceiling fan in bedroom number 2 needs 2 light bulbs.

Administrator was reminded that it is required to notify LPA, within 5 business days of admitting the first client. This notification may be done by phone, email or fax. Accordingly, Administrator will contact LPA to schedule the second pre-licensing inspection to verify the deficient items have been corrected. Administrator was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. LPA informed the Administrator that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. Exit interview was conducted and a copy of this report was provided to Administrator Erin Morris-Hernandez.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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