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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006520
Report Date: 01/24/2025
Date Signed: 01/24/2025 09:57:49 AM

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
12/05/2024 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20241205111824
FACILITY NAME:ALTER BEHAVIORAL HEALTH - CAPISTRANO BEACH, LLCFACILITY NUMBER:
306006520
ADMINISTRATOR:LEMME, WILLIAMFACILITY TYPE:
772
ADDRESS:33452 VIA DE AGUATELEPHONE:
(949) 538-7457
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 6DATE:
01/24/2025
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Whitney BussTIME COMPLETED:
10:12 AM
ALLEGATION(S):
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- Facility did not ensure that clients goals were documented in treatment plan
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Administrator (AD) Whitney Buss.
It was alleged that facility did not ensure that clients goals were documented in treatment plan. During the investigation LPA interviewed clients and staff; checked client files; and reviewed client pre-placement appraisal information; clinical progress notes; assessments; golden thread problem list; and clinical thread treatment plan. The investigation determined the following:
Per records obtained and reviewed, Client 1 (C1)’s clinical treatment plans for their diagnosed problems shows treatment started on October 22, 2024, and was not updated until November 15, 2024. In addition, records obtained show Client 2 (C2) started treatment plan October 1, 2024, and was updated on October 28, 2024. Following the update, C2’s treatment plan was updated again on November 12, 2024. Client 3 (C3) started treatment on December 05, 2024, but there are no updates in their treatment plan as of date of the initial date of complaint investigation December 10, 2024. Based on LPA’s review of records obtained, there are gaps in the notation and documentation of three of seven treatment plans reviewed. Per

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
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-20241205111824
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: ALTER BEHAVIORAL HEALTH - CAPISTRANO BEACH, LLC
FACILITY NUMBER: 306006520
VISIT DATE: 01/24/2025
NARRATIVE
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interviews with two of two staff, treatment plans get updated weekly; however, no evidence of weekly updates was found.

Therefore, based on the preponderance of evidence through records obtained and reviewed the allegation facility staff did not ensure that clients goals were documented in treatment plan is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.



The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with Administrator Whitney Buss and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241205111824
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: ALTER BEHAVIORAL HEALTH - CAPISTRANO BEACH, LLC
FACILITY NUMBER: 306006520
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
81068.3
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81068.3 Modifications to Needs and Services Plan(d) … The program director or staff person specified in (a) above shall, with the client's participation, review the treatment/rehabilitation plan according to the schedule set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Section 532.2(c). This requirement was not met as evidence by:
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Facility will provide proof of training or inservice about better documentation of treatment plans. Facility will provide written statement of understanding for regulation that was cited and email to LPA by POC due date.
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LPA’s review of three of seven client files, facility did not document treatment plans and goals weekly. This poses a potential health and safety risk to clients 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: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3