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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005677
Report Date: 03/07/2022
Date Signed: 03/07/2022 04:21:58 PM

Document Has Been Signed on 03/07/2022 04:21 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:
306005677
ADMINISTRATOR:DAN ROBINSONFACILITY TYPE:
772
ADDRESS:34142 CRYSTAL LANTERNTELEPHONE:
(949) 313-7444
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 6CENSUS: 5DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sherif Armanious and Dan RobinsonTIME COMPLETED:
03:32 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Client Coordinator Sherif Armanious. Client Coordinator Monica Lewis was present as well. Program Director Dan Robinson arrived during the visit.

At 2:20 PM, LPA toured the facility with Client Coordinator Armanious. Facility has 5 clients in care during today's visit. LPA observed clients in the facility participating in group therapy. All clients appeared well taken care of. Facility appears clean and sanitary. All client's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are single and double occupancy. Facility screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes client temperatures daily. Facility has covid precaution postings as well as all required department postings. Facility submitted mitigation plan to the department. LPA observed the emergency disaster plan posted in facility. LPA observed emergency food and water as well as the first aid kit. Facility has ample food supplies. LPA toured the outside grounds and observed the shaded outside visitation area. LPA observed the locked medication storage area. Facility has gloves, gowns, masks and N95 masks as well as cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation.
LPA consulted with Care Coordinator and Program Director on the importance of maintaining the "Let Us No" sign posted in regulation size, 20'"X 26."

No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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