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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005676
Report Date: 03/01/2022
Date Signed: 03/01/2022 04:01:46 PM

Document Has Been Signed on 03/01/2022 04:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005676
ADMINISTRATOR:MEGHAN MARCUMFACILITY TYPE:
772
ADDRESS:31101 PASEO VALENCIATELEPHONE:
(949) 313-7444
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Dan RobinsonTIME COMPLETED:
04:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA met with Administrator Dan Robinson. LPA explained the reason for the visit. LPA was granted entry into the facility. LPA and Administrator toured the facility. The facility is a two story home with 3 bedrooms, 3 bathrooms, dining room, living room, family room, laundry room, staff office and attached 3 car garage. LPA observed all resident rooms had the required furnishings. LPA observed all fire extinguishers are fully charged. Smoke/carbon monoxide detectors tested operational. Hot water in all 3 bathrooms measured above 120.0 degrees Fahrenheit. LPA and Administrator toured the kitchen. The kitchen is clean and organized. Sharp objects are kept locked in the staff office. Medications are kept locked in the staff office. LPA and the Administrator toured the garage. The garage is used for storage. Cleaning supplies are kept locked in the garage. LPA observed the fireplace in the family room and the fireplace in the master bedroom are not screened. No obstacles or hazards observed inside of the facility. LPA and Administrator toured the backyard of the facility. There is a covered patio with a table and chairs for clients. Both exit gates are operational. No bodies of water observed. No obstacles or hazards observed in the backyard. Administrator had facility maintenance adjust the hot water temperature during the visit. LPA consulted with the Administrator concerning the Health and Safety Code 1565 and continued Covid-19 mitigation procedures. Deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 2. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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 03/01/2022 04:01 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 03/01/2022 at 03:25 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: A MISSION FOR MICHAEL
FACILITY NUMBER: 306005676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(e)(1)

Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Deficient Practice Statement
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This requirement is not being met as evidenced by, LPA measured the hot water in all 3 bathrooms above 120.0 degrees Fahrenheit, which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Licensee states the hot water temperature will be adjusted to be between 105 and 120 degrees Fahrenheit by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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