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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006325
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:48:40 PM

Document Has Been Signed on 06/12/2024 03:48 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
ORANGE COUNTY RO, 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:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Britten Devereux- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after initiating a complaint investigation in connection to Complaint Control Number: 22-AS-20240606121507. LPA stated the purpose of the visit to Administrator Britten Devereux. LPA observed Staff #1 (S1) was not fingerprint cleared and Staff #2 (S2) was not associated per the Licensing Information System (LIS) dated June 11, 2024 and the Guardian Employee Roster dated June 12, 2024 as required per the Criminal Record Clearance of the Title 22 Regulations. S1 stated that they were employed on April 17, 2024 and S2 on April 11, 2024. S2 was associated S1 completed their live scan during the visit.

A deficiency is 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 with Administrator Britten Devereux, and a copy of this report including the LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 03:48 PM - It Cannot Be Edited


Created By: Jessica Cho On 06/12/2024 at 03:22 PM
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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2024
Section Cited
CCR
81019(e)(1-2)

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81019 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department; or (2) Request a transfer of a criminal record clearance…

This requirement was not met as evidenced by:
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Proof of live scan for S1 was received and S2 was associated during the visit. Administrator stated that they will review and submit an Acknowledgement of Understanding for the said deficiency to LPA by POC due date. Additionally, Admin will submit the proof of DOJ clearance letter to LPA by Monday, June 24, 2024.
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Based on observations, interviews, and record review, facility did not maintain a fingerprint clearance for S1 and associated S2 which poses an immediate 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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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