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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005677
Report Date: 02/10/2025
Date Signed: 02/10/2025 10:41:01 AM

Document Has Been Signed on 02/10/2025 10:41 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:
306005677
ADMINISTRATOR/
DIRECTOR:		DAN ROBINSONFACILITY TYPE:
772
ADDRESS:34142 CRYSTAL LANTERNTELEPHONE:
(949) 313-7444
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 6CENSUS: 4DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:18 AM
MET WITH:Ashley DouglasTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA was greeted and granted entry into the facility and explained the reason for the visit.
Facility is licensed for six ambulatory clients and there are four clients currently admitted to the facility. Upon entry, LPA observed the facility temperature was 55 degrees F.
LPA Lyman along with Compliance Coordinator Kerri Bamper toured the facility at 8:00 AM. Clinical Director Kristian Concepcion joined the tour in progress. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of three stories with three client bedrooms on the third floor, living room, dining room, and kitchen on the main second floor and one therapy room/ restroom on the first floor. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 92.3 and 103.7 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is an outside smoking area for clients. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 01/13/2025 and drills are conducted monthly. Facility provides activities in the form of exercise and community outings. LPA reviewed four client files and four staff files during the visit. Client files contained all required documents. Staff files reviewed contained required documentation of training and all pertinent paperwork including CPR/ First aid. LPA reviewed medication storage and administration. CONT ON LIC 809C DATED 02/10/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MICHAEL
FACILITY NUMBER: 306005677
VISIT DATE: 02/10/2025
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Medications are stored in a locked medication room and are being administered per physician order.

Licensee to forward an updated emergency disaster plan to LPA by 02/24/2025.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2025 10:41 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 02/10/2025 at 10:06 AM
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: 306005677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

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 in two out of two faucets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee to adjust water and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
81088(a)(1)
A comfortable temperature for clients shall be maintained at all areas.
The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 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. Facility temperature is 55 degrees upon arrival which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee to address heating issues and forward proof to LPA by POC due date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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