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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005676
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:05:31 PM

Document Has Been Signed on 02/27/2024 03:05 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
ORANGE COUNTY RO, 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: 4DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Marissa Mara, Executive DirectorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing a required annual inspection. LPA arrived at the facility was greeted and granted entry by staff. LPA met with Marissa Mara, Executive Director and explained the nature of the visit.

Four clients currently reside at this location, all clients were present at the time of the visit. LPA accompanied by Executive Director began the tour of the inside and outside of the facility, the facility is a two-story house. LPA observed the required department postings throughout the facility. The facility was observed to stay within the capacity limitations. LPA toured the garage and observed there was a storage cabinet for toxins locked and a spare refrigerator for food storage. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables food available. LPA inspected the medication room and observed mediation room to be locked with a locked storage cabinet with medication. Medication is labeled and stored inaccessible to clients in care. LPA inspected clients bedrooms and it was observed they hac sufficient lighting to ensure the safety and comfort of the clients. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. The facility has an available clean supply of linens. LPA inspected facility bathrooms and observed that bathrooms had a supply of soap, toilet paper and towels for clients use. LPA measured the hot water temperature which measured 114.6 Fahrenheit degrees. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways to be free of obstruction. LPA observed several seating areas for client’s enjoyment. LPA observed several fire extinguishers with service date of September 26, 2023, charged and mounted on the walls throughout the facility, fire drills are

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: A MISSION FOR MICHAEL
FACILITY NUMBER: 306005676
VISIT DATE: 02/27/2024
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conducted quarterly. LPA reviewed four client records, records are kept electronically and were made available to LPA. All the required documentation was present and current in the client’s files reviewed. LPA reviewed two employee records. All employees present have a criminal records clearance and are associated to the facility. LPA observed records reviewed have a current first aid certificate.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Executive Director and a copy of this report was provided and left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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