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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604864
Report Date: 08/14/2025
Date Signed: 08/14/2025 10:41:19 AM

Document Has Been Signed on 08/14/2025 10:41 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:WINGS RECOVERY CENTER, LLCFACILITY NUMBER:
374604864
ADMINISTRATOR/
DIRECTOR:		HOSLAR, KATYFACILITY TYPE:
735
ADDRESS:3134 MORNINGSIDE DRIVETELEPHONE:
(858) 220-9519
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 2DATE:
08/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Carlos Montano and Cecilia SteinbachTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to deliver investigative findings. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Carlos Montano and Director of Operations Cecilia Steinbach.

On 4/7/2025, the Department received a self-reported incident report regarding Client 1 (C1) and conducted a case management visit on 4/9/2025 to follow up on the incident. Review of C1’s Admission Agreement and medical records revealed that C1 was admitted to the facility on 3/26/2025 after being discharged from the hospital due to a suicide attempt which occurred in early March 2025 and resulted in C1 being hospitalized from 3/9/2025 to 3/26/2025. Review of C1’s pre-admission assessment documents revealed that C1 had a history of suicidal ideation (SI), a family history of suicide, and had a history of at least two prior suicide attempts. Assessment records noted that C1 had both pre-planned and spontaneous suicide attempts. Additionally, C1 reported experiencing suicidal ideation 2-5 times a week. Assessment records provided conflicting information regarding the severity of C1’s SI. C1 reported that suicidal thoughts ranged between fleeting, lasting only a few moments and lasting between 4-8 hours a day. Additionally, C1’s ability to control those thoughts varied between easily controlled and unable to control thoughts. C1 was assessed to be at serious risk of suicide harm. Interviews revealed that facility management and staff were aware of C1’s SI and past suicide attempts and were aware that C1 was at an increased risk of suicide.

Continued on LIC809-C page...
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WINGS RECOVERY CENTER, LLC
FACILITY NUMBER: 374604864
VISIT DATE: 08/14/2025
NARRATIVE
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Interviews with facility management and staff revealed that on 4/4/2025 at approximately 6:00pm, C1 had a virtual psychiatry assessment. Review of the psychiatric assessment document revealed that C1 did not express any SI during that assessment, however according to facility management, the assessment information was not reviewed by management or staff prior to the outing. Review of the incident report revealed that on 4/4/2025, facility staff took C1 and another client, Client 2 (C2) on an outing to a non-licensed property overseen by the Licensee. Interviews with clients, staff, and outside sources revealed that at approximately 7:00pm, C1, C2, and other individuals went up to the rooftop terrace located above the 3rd floor of the non-licensed property to watch a movie. Photographs taken by the Department during the investigation revealed that the rooftop terrace was overlooking a driveway and that the walls overlooking the driveway were approximately 3 to 4 feet high. Interviews with staff revealed that Staff 1 (S1) and Staff 2 (S2) both remained downstairs for approximately 5 minutes before S1 went up to the rooftop terrace to supervise C1 and C2. Interviews with management staff revealed that management staff approved of the outing to the non-licensed property if staff maintained “line-of-sight” supervision, however, review of an email chain between facility management and staff on 4/4/2025 did not reveal any specific direction to provide “line-of-sight” supervision, and only had a statement to “observe the… clients the entire time”. Facility management stated that after the email conversation, S1 was provided with verbal direction to provide “line-of-sight” supervision to C1 and C2.

Interviews with staff and outside sources revealed that at approximately 9:00pm, S1 informed C1 and C2 that it was time to return to the facility for medications. S1 and C2 walked downstairs, and S1 stated during interviews that they believed that C1 followed them downstairs, but S1 became aware that C1 had not followed S1 downstairs. S1 waited a short time before S1 returned upstairs to remind C1 that they needed to leave. At that time, S1 observed C1 to be standing near the wall with C1’s hands on the railing. S1 reminded C1 that they needed to leave again and after waiting a few minutes, S1 began walking towards C1. S1 noted during interviews that C1 did not acknowledge S1’s presence or reminders until S1 started walking towards C1. S1 stated that C1 then backed up to and hopped over the wall and held onto the railing for a short period of time before C1 let go, fell, and landed on the windshield of a van. Staff called 911 and both paramedics and San Diego Sheriff responded to the non-licensed property.

Continued on LIC809-C page...
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WINGS RECOVERY CENTER, LLC
FACILITY NUMBER: 374604864
VISIT DATE: 08/14/2025
NARRATIVE
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Review of records from the San Diego Sheriff Department revealed that C1 sustained a laceration to the head and an injury to the right elbow, resulting in hospitalization. Despite subpoena requests and multiple attempts to interview C1, the Department was unable to interview C1 or obtain copies of C1’s medical records to determine if C1 obtained any additional or more severe injuries.

The Department has investigated the above incident and based on interviews and records review, the preponderance of the evidence has been met, therefore, a violation of the regulations has occurred. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page. Additionally, The Department has determined this violation resulted in injuries to a client in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. At this time, per Health and Safety Code Section 1548, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division.

An exit interview was conducted with Executive Director Carlos Montano and Director of Operations Cecilia Steinbach, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 03/22).
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 10:41 AM - It Cannot Be Edited


Created By: Rebecca A Borunda On 08/14/2025 at 09:41 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WINGS RECOVERY CENTER, LLC
FACILITY NUMBER: 374604864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client’s needs:
This requirement has not been met as evidenced by:
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All staff received training on SAFE-T assessment, suicide risk and impulsiveness on 7/1/2025 and had a post-training test. ED will provide copies of the updated policies and proof of staff training to the Deparment by POC due date of 8/18/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above in that staff were aware that C1 was at a high risk of suicide attempt and was able to attempt suicide, resulting in hospitalization. This posed an immediate health and safety risk to C1.
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ED stated that clients are no longer allowed to visit that non-licensed property. ED stated they updated policies regarding outings, rounding frequency, and ensuring clients are back at the facility for medication passes.

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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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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