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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006200
Report Date: 11/18/2025
Date Signed: 11/18/2025 11:47:50 AM

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
10/31/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251031171256
FACILITY NAME:SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLCFACILITY NUMBER:
306006200
ADMINISTRATOR:VILLARREAL, MICHAELFACILITY TYPE:
772
ADDRESS:25681 SABINA AVETELEPHONE:
(949) 533-4025
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Michael Villarreal and Program Director Andrew CrawfordTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not follow the required staffing ratios
Facility did not complete clients Needs and Services plan timely
Facility did not adhere to clients treatment plan
Facility staff do not meet the minimum requirements
Facility staff did not complete the required training hours
INVESTIGATION FINDINGS:
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On November 18, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Michael Villarreal and Program Director were notified via telephone and later arrived to assist with the inspection.

During the course of the investigation, LPAs interviewed staff and clients, obtained and reviewed facility records. Regarding the allegation that, facility did not follow the required staffing ratios, the following has been concluded: LPAs reviewed the Southern California Sunrise Recovery Center, LLC staff schedule dated September 1, 2025, through September 30, 2025. LPAs observed that there were multiple shifts in which there was only one staff on duty. For example, on September 2, 2025, there was only one staff on duty for the shift of 4:00 PM to 12:30 AM. From September 3, 2025, through September 6, 2025, there was only one staff on duty for the shift of 12:00 AM to 8:30 AM. On September 7, 2025, there was only one staff on duty for each shift. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
VISIT DATE: 11/18/2025
NARRATIVE
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On September 10, 2025, through September 12, 2025, there was only one staff on duty for the shift of 12 AM to 8:30 AM. From September 17, 2025, through September 21, 2025, there was only one staff on duty for the shift of 12 AM to 8:30 AM. Additionally, from September 24, 2025, through September 27, 2025, there was only one staff on duty for the shift of 12 AM to 8:30 AM. LPAs conducted five staff interviews. Five out of the five staff interviewed confirmed there have been shifts in September in which there were only one staff on duty due to staffing shortages. LPAs conducted three client interviews. Three out of the three clients interviewed confirmed there have been shifts where there have only been one staff on duty. Per California Code of Regulation under Day Staff Client Ratio 81065.5 (a)(2), it states that Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility did not complete client’s Needs and Services plan timely, the following has been concluded: It was alleged that Client #3 (C3) Needs and Services plan was not completed in a timely manner. LPAs observed that C3 was admitted to the facility on October 3, 2025. LPAs observed that C3’s Needs and Services plan was completed on October 8, 2025. Per California Code of Regulation under Needs and Services Plan 81068.2 (b), it states that the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission. Based on records reviewed, LPAs observed that C3’s Needs and Services plan was not completed within 72 hours of admission. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility did not adhere to client’s treatment plan, the following has been concluded: It was alleged that the facility did not adhere to the treatment plan for Client #1 (C1) and Client #3 (C3). LPAs reviewed the treatment plans for both C1 and C3. LPAs observed that the treatment plan for C1 was established on October 1, 2025. LPAs observed that in C1’s treatment plan, it states that for the first goal, the facility will assist the client in establishing a relapse prevention plan with three warning signs, three coping skills, and three people/places to manage and regulate sequent episodes. It states that a staff will review C1’s progress once a week in sessions. LPAs reviewed the weekly session progress notes for C1 and observed that on October 8, 2025, and October 15, 2025, it does not document C1’s progress towards reaching the established goal in creating a relapse prevention plan with three warning signs, three coping skills, and three people/places to manage and regulate sequent episodes. LPAs observed that the treatment plan for C3 was established on October 6, 2025. LPAs observed that in C3’s treatment plan, it states that for the first goal, the client will learn and implement emotional regulation skills from zero to one time a week, to four to five times a week. It states that a staff will monitor C3’s progress once a week in sessions. LPAs reviewed the weekly session progress notes for C3 and observed that on October 15, 2025, it does not document C3’s progress towards reaching the established goal of learning and implementing emotional regulation skills from zero to one time a week, to four to five times a week. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
VISIT DATE: 11/18/2025
NARRATIVE
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LPAs observed that the treatment plan for C3 was established on October 6, 2025. LPAs observed that in C3’s treatment plan, it states that for the first goal, the client will learn and implement emotional regulation skills from zero to one time a week, to four to five times a week. It states that a staff will monitor C3’s progress once a week in sessions. LPAs reviewed the weekly session progress notes for C3 and observed that on October 15, 2025, it does not document C3’s progress towards reaching the established goal of learning and implementing emotional regulation skills from zero to one time a week, to four to five times a week. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff do not meet the minimum requirements, the following has been concluded: Per California Code of Regulation under Personnel Requirements 81065 (n), it states that 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). These requirements include that all direct care staff shall have graduated from high school or possess a GED and have a minimum of one year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities. Such experience shall be in direct services to clients. 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. The plan should include but not be limited to the frequency and number of hours of training, the subjects to be covered, and a description of the supervision to be provided. LPAs reviewed five staff files. LPAs observed that five out of the five staff did not meet the one year of full-time experience requirement, thus requiring an appropriate plan of supervision. LPAs reviewed the plan of supervision for all five staff. LPAs observed that the plan of supervision for all five staff states the training that the staff will complete within the first ninety days of employment. However, the plan of supervision does not describe how the facility will ensure ongoing qualification for the staff to perform the job, including details about number of hours of training, the subjects to be covered, and a description of the supervision to be provided after the first ninety days of employment for the staff. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff did not complete the required training hours, the following has been concluded: Per California Code of Regulation under Personnel Requirements 81065 (r)(2), it states that all direct care staff shall receive a minimum of 20-clock-hours of continuing education per year, which shall provide the staff with the knowledge and skills as appropriate to their job assignment. CONTINUED ON LIC9099-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
VISIT DATE: 11/18/2025
NARRATIVE
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It further states that the licensee shall document the number of hours of continuing education completed each year by direct care staff. LPAs reviewed the training records for five staff. LPAs observed that the training records for Staff #1 (S1) does not specify the number of training hours that S1 completed in the year 2024. Therefore, the Department is unable to determine if S1 completed the required annual training due to the Licensee not documenting the number of hours completed as required by regulations. LPAs observed that the facility did not document the number of hours of training Staff #2 (S2) completed in the year 2024. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

An exit interview was conducted with Licensee Michael Villarreal. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
81065.5(a)(2)
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81065.5 DAY STAFF-CLIENT RATIO
:(a) A licensee shall ensure that sufficient direct care staff are at the facility.. (2) Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility. This requirement is not evidenced by:
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The Licensee stated that they will provide LPAs with the November 2025 staffing schedule to confirm that the facility now has sufficient staffing. The Licensee agreed to provide LPAs the staffing schedule via email or fax by POC date.
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Based on interviews conducted and records reviewed, the Department observed that there were multiple shifts in September 2025 in which only one staff was on duty. This poses a potential health and safety risk to persons in care.
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Type B
12/05/2025
Section Cited
CCR
81068.2(b)
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81068.2 NEEDS AND SERVICES: (b) For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission, that must include:
This requirement is not evidenced by:
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The Licensee stated that they will complete a statement that they will comply with the regulation moving forward. The Licensee agreed to provide LPAs the statement via email or fax by POC date.
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Based on records reviewed, LPAs observed that the Needs and Services plan for Client #3 was not completed within 72 hours of admission. This poses a potential health, safety, 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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
81068.3(d)
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81068.3 Modifications to Needs and Services Plan (d)The program director or staff ... shall, with the client's participation, review the treatment/rehabilitation plan according to .. California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Section 532.2(c).
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The Licensee stated that they will complete a statement to comply with clients treatment plans moving forward. The Licensee agreed to provide the statements to LPAs via email or fax by POC date.
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This requirement is not evidenced by: Based on records reviewed, LPAs observed that the facility did not adhere to the treatment plans for Client #1 and Client #3. This poses a potential health, safety, and personal rights risk to persons in care.
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Type B
12/05/2025
Section Cited
CCR
81065(n)
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81065 Personnel Requirements: (n) 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 is not evidenced by:
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The Licensee stated that they will modify their plan of supervision to ensure the staff's on going qualifications are met. The Licensee agreed to provide LPAs the modified plan of supervision to ensure it meets compliance via email or fax by POC date.
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Based on records reviewed, LPAs observed that the plans of supervision for the five facility staff were not sufficient as it did not document how the facility will ensure the ongoing qualifications for the staff after the first ninenty days of employment. This poses a potential health, safety, and personal rights risk.
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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: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 22-AS-20251031171256
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: SOUTHERN CALIFORNIA SUNRISE RECOVERY CENTER LLC
FACILITY NUMBER: 306006200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
81065(r)
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81065 Personnel Requirements: (r) All direct care staff shall receive a minimum of 20-clock-hours of continuing education per year, which shall provide the staff with the knowledge and skills as appropriate to their job assignment. This requirement is not evidenced by:
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The Licensee stated that they will create a consistent plan of training that each staff will complete on a yearly basis, documenting the number of hours completed and the type of training completed. The Licensee agreed to provide LPAs this plan of training via email or fax by POC date.
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Based on records reviewed, LPAs observed that the facility did not document the number of hours Staff #1 completed in 2024 or the number of hours and specific training that Staff #2 completed in 2024. This poses a potential health, safety, and 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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9