306006325-10-11-2023-22-AS-RMAZ-CWHNA3-20231011101653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006325
Report Date: 10/11/2023
Date Signed: 10/11/2023 10:17:00 AM

Document Has Been Signed on 10/11/2023 10:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFIC SOLSTICE LLC		FACILITY NUMBER:	306006325
ADMINISTRATOR:	DEVEREUX, BRITTEN		FACILITY TYPE:	772
ADDRESS:	307 EAST AVENIDA CORDOBA		TELEPHONE:	(949) 200-7929
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY: 6		CENSUS: 0	DATE:	10/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ramsden Florento		TIME COMPLETED:	10:30 AM

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) Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. An initial application to operate a Social Rehabilitation Facility was submitted to CCL on 02/21/2023 for (6) capacity ambulatory clients. Structure: The facility is a one-story house with an attached garage with 3 client bedrooms, 2 full bathrooms, a kitchen, a dining room and 1 living room. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is a large backyard with an exit walkway on each side of the house with covered seating for the clients. Air/Heating: Central air/heating system installed with a central panel to control entire house. Client Residents: Bedrooms will accommodate 6 clients with 3 shared rooms accommodating two clients. Bedrooms Staff: No bedroom designated for awake-staff. Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SOLSTICE LLC	FACILITY NUMBER: 306006325
	VISIT DATE: 10/11/2023

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway space.

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.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, tested and found operational.

Appliances:
5 gas burner stove, 2 ovens, 2 refrigerators (1 in attached garage), 1 freezer, dishwasher, microwave, 2 washer, and 2 dryers are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants inaccessible to clients are stored in garage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 118.9 Fahrenheit degrees in bathrooms.

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SOLSTICE LLC	FACILITY NUMBER: 306006325
	VISIT DATE: 10/11/2023

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Medications, First-Aid Kit & Book:
In locked storage closet between kitchen and bedroom hallways.

Client & Staff Files:
Records will be kept locked with medication storage.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on 03/22/2023.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Applicant 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.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

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