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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006466
Report Date: 05/16/2025
Date Signed: 05/16/2025 01:34:57 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
05/08/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20250508155524
FACILITY NAME:PACIFIC COAST MENTAL HEALTHFACILITY NUMBER:
306006466
ADMINISTRATOR:CISNA, DEREKFACILITY TYPE:
772
ADDRESS:2798 WAXWING CIRCLETELEPHONE:
(949) 480-7126
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
05/16/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Soren ShamsianTIME COMPLETED:
01:47 PM
ALLEGATION(S):
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Facility did not document anticipated client length of stay
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint inspection to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility did not document anticipated client length of stay. During the investigation, LPA conducted interviews with clients in care and staff. LPA reviewed client records obtained.

The investigation determined as follows: regarding the allegation facility did not document anticipated client length of stay, it was reported client records for client 1, 2, and 3 did not contain documented evidence of an anticipated length of stay needed to accomplish identified goals.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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 3
Control Number 22-AS-20250508155524
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: PACIFIC COAST MENTAL HEALTH
FACILITY NUMBER: 306006466
VISIT DATE: 05/16/2025
NARRATIVE
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The admission date for client 1 was March 18, 2025. The admission date for client 2 was April 3, 2025. The admission date for client 3 was March 23, 2025.

LPA interview with Program Director (PD) Dr. Soren Shamsian revealed initial length of stay for newly admitted clients is assessed within 24 hours of admission and documented in the initial treatment plan. Initial length of stay is assessed between 30 and 60 days. Within 72 hours, the client is reassessed in a master treatment plan with identified goals. Length of stay is adjusted based on the client's progress weekly. For clients 1, 2 and 3, length of stay was not documented in their master treatment plan until after April 15, 2025. PD stated prior to April 15, 2025, the master treatment plan did not have a specific space to document length of stay in the form. They now use an updated form to document length of stay in the master treatment plan.

LPA interview with three out of three current clients recall being told verbally their initial length of stay would be between 30 to 45 days at the time of admission. Two out of three clients stated they feel they have made progress during their stay. One out of three clients stated they have not been at the facility long enough to assess progress. Three out of three clients stated they feel their needs are being met at this time.

Based on interviews conducted, observation, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 2), is being cited on the attached LIC 9099D.

An exit interview was conducted with Dr. Soren Shamsian and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20250508155524
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: PACIFIC COAST MENTAL HEALTH
FACILITY NUMBER: 306006466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2025
Section Cited
CCR
81068.2(b)(3)
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81068.2(b)(3) Needs and Services Plan
For each client admitted, the licensee shall ensure that a written Needs and Services Plan... must include: A written treatment... plan as required by California Code of Regulations, title 9,... section 532.2(c).
This requirement is not met as evidenced by:
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Facility updated master treatment plan to include length of stay and provided a copy to LPA during the inspection.
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Based on LPA record review and staff interview, needs and services plan for clients 1, 2, and 3 did not meet the requirement of documenting length of stay which poses a potential health and safety 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3