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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006325
Report Date: 12/06/2024
Date Signed: 12/09/2024 08:05:27 AM

Document Has Been Signed on 12/09/2024 08:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFIC SOLSTICE LLCFACILITY NUMBER:
306006325
ADMINISTRATOR/
DIRECTOR:		DEVEREUX, BRITTENFACILITY TYPE:
772
ADDRESS:307 EAST AVENIDA CORDOBATELEPHONE:
(949) 200-7929
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 6CENSUS: 3DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:25 AM
MET WITH:Jez LymanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias are conducting this unannounced visit for the purpose of completing an annual required inspection. Upon arrival, LPAs were denied entry into the facility and allowed entry into the garage only. Staff did not provide requested documents or answer LPAs' questions. LPA spoke with Les Johnson who referred LPA to Administrator Deveraux by telephone. LPAs were granted entry into the facility at 7:50 to conduct the physical plant tour. Facility is licensed for six ambulatory clients.
LPAs Lyman and Arias along with Staff Eduardo Manzo toured the facility at 7:59 AM. LPAs toured the physical plant, checked food service, and reviewed medications. The home consists of three client bedrooms, two common restrooms, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly and shower was free of mold/mildew. Water temperature measured between 113.7 and 115.3 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. At 8:15 AM, LPAs observed exit #4 off the medication room is secured with a lock outside the door preventing the door from opening from the inside. First aid kit had all the required elements. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample shaded seating for clients. Exit gates are unlocked and operational. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility does not have documentation of required emergency drills. Facility provides activities in the form of exercise and karaoke. LPAs reviewed medication storage and administration. Medication is being administered per physician order and are stored in an locked medication room. LPAs requested staff and client records. Facility is unable to provide requested documents. Upon arrival to facility, LPAs verified Staff Manzo's criminal background clearance. The staff is not cleared. CONT ON LIC 809C DATED 12/06/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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: PACIFIC SOLSTICE LLC
FACILITY NUMBER: 306006325
VISIT DATE: 12/06/2024
NARRATIVE
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Deficiencies are being cited as per the Title 22, Division 6, Chapter 2 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted and a copy of this report including the LIC421BG and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/09/2024 08:05 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/06/2024 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SOLSTICE LLC
FACILITY NUMBER: 306006325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff 1 is not cleared or associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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2
3
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Licensee to obtain criminal record clearance for Staff 1 and forward proof to LPA by POC due date.
Request Denied
Type A
Section Cited
CCR
80020
All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. Exit door #4 is secured with a lock outside the door preventing the door from opening from the inside which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Licensee to remove the lock and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/09/2024 08:05 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/06/2024 at 11:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SOLSTICE LLC
FACILITY NUMBER: 306006325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
81044(a)
The licensing agency shall have the inspection authority specified in Health and Safety Code sections 1526.5, 1533(a), 1534 and 1538.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs were denied entry for approx 30 minutes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Licensee to provide a statement of understanding of the regulation to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/09/2024 08:05 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/06/2024 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SOLSTICE LLC
FACILITY NUMBER: 306006325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
81064(a)
Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There is no designated back up administrator on-site which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee to submit an updated LIC 308/ 500 indicating back up administrators by POC due date.
Request Denied
Type B
Section Cited
CCR
81044)(c)
The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements specified in Sections 81066(e) and 81070(d).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Facility is unable to provide requested documents to LPAs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee to provide the following documents by POC due date: Client records including admission agreements/ physician reports and appraisals for Clients 1-3 and Staff training/ health screen/ TB for Staff 1-4.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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