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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006466
Report Date: 10/31/2025
Date Signed: 10/31/2025 04:07:26 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
10/23/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251023114934
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:
10/31/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Johnny MartinezTIME COMPLETED:
04:21 PM
ALLEGATION(S):
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Staff allowed client in care to purchase cigarettes illegally
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize 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 staff allowed client in care to purchase cigarettes illegally. During the investigation, LPA conducted interviews with staff. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff allowed client in care to purchase cigarettes illegally, it was reported during a supervised outing, client 1 (C1) was allowed to enter a smoke shop and purchase cigarettes and a vape. LPA interviews with two out of six staff stated staff did purchase a vape for C1 who is under the legal age to vape. The remaining four staff did not add anything relevant to the allegation. LPA record review revealed the facility management conducted an internal investigation when concerns were brought to their attention regarding this allegation.
Continued on LIC9099-C dated 10/31/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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 5
Control Number 22-AS-20251023114934
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: 10/31/2025
NARRATIVE
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The report indicated staff did purchase a vape for C1 who was underage and corrective action was taken including coaching staff to reinforce understanding of policies and updating procedures to include taking an emergency binder with client face sheet and medication list during outings. Admission agreement for C1 indicated C1 is under the age of 21.

Based on interviews conducted 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 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: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20251023114934
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: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2025
Section Cited
CCR
81065(a)
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81065(a) Personnel Requirements
Facility personnel shall be competent to provide the services necessary to meet individual client needs...

The requirement is not met as evidenced by:
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Facility management has conducted training with staff and updated procedures to prevent from happening again. Facility provided report to LPA during visit.
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Staff purchased a vape for C1 as an underaged client which poses an immediate 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: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5