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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005676
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:55:26 AM

Document Has Been Signed on 02/08/2023 11:55 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
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:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dan RobinsonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by Staff Natalie Maalouf and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and Staff Diana Flores conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a two-story house with three client bedrooms, and three bathrooms. During the inspection LPA observed two Staff and two Therapists present with six clients in care. Clients were observed engaging in individual and group therapy. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. LPA confirmed the facility has a 30-day supply of PPE on hand. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding client screening, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Program Director Dan Robinson arrived at 11:22 a.m. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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