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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005676
Report Date: 02/26/2025
Date Signed: 02/26/2025 04:59:40 PM

Document Has Been Signed on 02/26/2025 04:59 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/
DIRECTOR:		MEGHAN MARCUMFACILITY TYPE:
772
ADDRESS:31101 PASEO VALENCIATELEPHONE:
(949) 313-7444
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 4DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Lauren Grizzle, Eric Schlothan TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Program Manager Lauren Grizzle and explained the reason for the visit. LPA and the Program Manager toured the facility. Facility is a 3 bedroom, 3 bathroom, two story house with a kitchen, dining room, living room, family room, laundry room, therapy room and an attached 2 car garage. Facility is licensed for 6 ambulatory clients. LPA observed the fireplace in the family room is screened. The facility license is posted on the wall next to the front door. LPA observed all fire extinguishers are fully charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. All appliances, refrigerator, electric stove, dishwasher and 2 ovens are clean and operational. LPA observed all medications and knives are kept locked in the downstairs storage closet. The garage is kept locked and used for storage. All cleaning supplies are kept in the garage. LPA and the Program Manager toured the second floor of the facility. The second floor is comprised of 3 client rooms and a therapy room (formerly the staff office). LPA observed all client rooms had the required furnishings and linens. LPA observed the emergency evacuation chair at the top of the stairway is mounted on the wall. LPA observed the master bedroom has a fireplace that is screened. There are 2 bathrooms upstairs, both bathrooms are clean and operational. Hot water measured 121.0 degrees Fahrenheit. LPA observed clean linens in the hall closet. LPA and the Program Manager toured the backyard. There is a covered patio with a table and chairs to sit outside. LPA observed the exit gate is operational. No bodies of water observed. No obstacles or hazards observed in the backyard. LPA reviewed 4 client records and medication. No discrepancies observed. LPA reviewed 4 staff files, no discrepancies observed. The 4 staff members have all the required training. All staff present at the facility are background cleared and associated to the facility. Facility has a dedicated laptop for client use. Smoke detectors/carbon monoxide detectors tested operational. The last emergency drill was conducted on January 27, 2025. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 04:59 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/26/2025 at 04:51 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: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above , LPA measured the hot water in the upstairs shared bathroom and it measured 121.0 degrees Fahrenheit which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee agrees to adjust the hot water so it measures between 105.0 to 120.0 degrees Fahrenheit in all bathrooms.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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