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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006171
Report Date: 02/06/2026
Date Signed: 02/06/2026 04:43:43 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
01/13/2026 and conducted by Evaluator Jessica Cho
COMPLAINT CONTROL NUMBER: 22-AS-20260113095535
FACILITY NAME:ABLELIGHT, INC. -- PAPAGAYOFACILITY NUMBER:
306006171
ADMINISTRATOR:THERESA AMEDO, MARIAFACILITY TYPE:
735
ADDRESS:26372 PAPAGAYO DRTELEPHONE:
(949) 830-8629
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 3DATE:
02/06/2026
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Maria Amedo- Administrator
Michelle Torres- Lead Direct Support Professional		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not properly trained.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegation. LPA met with Lead Direct Support Professional (DSP) Michelle Torres followed by Administrator Maria Amedo and explained the reason for the visit. During the course of the investigation, LPA interviewed six (6) staff, reviewed eight (8) personnel files associated to the facilty, and obtained the following documentation for review: Client/Staff Rosters, Clients' Face Sheets, Physician's Reports, Individual Program Plans, Individual Service Plan, Behavior Intervention Plans, Personnel Certificates for First Aid/CPR Training, Safety-Care Training, Safety-Care Specialist Manual, Health Screening Reports, Tuberculosis Test Results, and Program Design.

The investigation is as follows: Regarding the allegation, Staff are not properly trained, it is alleged that the involvement of the Board Certified Behavior Analyst (BCBA) or behavior consultant is lacking and staff are receiving insufficient training leaving staff undertrained to manage clients with significant behavioral needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
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 3
Control Number 22-AS-20260113095535
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: ABLELIGHT, INC. -- PAPAGAYO
FACILITY NUMBER: 306006171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2026
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

This requirement was not met as evidenced by:
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Adminstrator stated that they will forward proof of 2 First Aid/CPR and four Safety Care certificates and a written Acknowledgement of Understanding of the said regulation to LPA by POC due date. One First Aid/CPR certificate was completed after the initial visit.
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Based on the review of the personnel files, three of eight staff did not have First Aid/CPR certificates and four of eight staff did not have the Safety-Care training which poses a potential Health, Safety, and/or Personal Rights 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260113095535
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: ABLELIGHT, INC. -- PAPAGAYO
FACILITY NUMBER: 306006171
VISIT DATE: 02/06/2026
NARRATIVE
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Based on the interviews, four out of six staff confirmed not receiving Safety-Care training upon hire. Six of six staff confirmed Client #1 (1) displaying physical aggression such as hitting, yelling, biting, pushing, and scratching other clients and staff which was also verified on C1's IPP dated September 29, 2025. Five of six staff indicated that the Safety-Care training is insufficient to safely handle C1's behaviors. Based on the complete file review of eight (8) personnel that are associated to this facility per the Personnel Report Summary (LIC500) dated January 5, 2026 and February 6, 2026, three staff are missing the First Aid/CPR certificates and four staff are missing the Safety-Care training/certificates. Based on the review of the Program Design, page 44 notes that all DSPs or care staff are to maintain current certification in First Aid, CPR, Safety Care, and Health Screening. The Safety Care training per page 1 of the curriculum manual, notes that the training program is designed for staff working with adults who may exhibit challenging or dangerous behaviors and how to respond to behavioral crises which is also similar to the training from the Crisis Prevention Institute (CPI). The behavior intervention plans dated January 31, 2025 and December 28, 2025 does not address the strategies when encountering C1's physical aggressions. Six of six staff confirmed not receiving training on how to handle physical aggressions from the behavior consultant.
The investigation reveals that there is sufficient corroborating evidence that staff are not properly trained.

Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, and the above allegation is deemed SUBSTANTIATED. A deficiency is being issued on the attached LIC9099D.

An exit interview was conducted with Administrator Maria Amedo, and a copy of this report including the Confidential Names (LIC811), and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3