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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005787
Report Date: 03/15/2023
Date Signed: 03/15/2023 11:38:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220314093445
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005787
ADMINISTRATOR:WILLIAM MARAFACILITY TYPE:
772
ADDRESS:33721 BLUE LANTERNTELEPHONE:
(949) 371-3857
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 0DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jason ShipleyTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Resident's requests for assistance were not responded to in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an attempted visit at the facility. LPA contacted Program Director Jason Shipley who stated would be there shortly.

Licensing Prgram Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Program Director Jason Shipley and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as medication orders and facility notes. Regarding the allegation that resident's requests for assistance were not responded to in a timely manner, the investigation revealed the following: At 9:00 PM on 02/22/2022, Client 1(C1) was exhibiting aggressive behavior and pushed a group of clients in the facility and then tumbled down facility spiral staircase. Per facility, C1 was assessed and stated that pain level was a 10/10. Staff contacted Program Director Shipley who received an order from physician to send the client to CONTINUED ON LIC 9099C DATED 03/15/2023
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 22-AS-20220314093445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2023
Section Cited
CCR
80075(A)
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The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not being met as evidenced by:
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Licensee to submit a statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on record review and interviews conducted, the licensee failed to ensure necessary emergency services were provided to client. Client fell down the stairs and 911 was not called. An hour and a half elapsed before medical attention was sought. This poses an immediate health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20220314093445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005787
VISIT DATE: 03/15/2023
NARRATIVE
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the hospital for assessment. Client was taken by car to Mission Hospital Laguna Beach at 10:25 PM and was released around 4 AM with prescription for pain relievers. CT scan was clear and no other injuries noted besides back pain. Per staff, clients involved in the incident offered to call 911 but staff declined in lieu of contacting facility nurse. Emergency medical attention was not sought for an hour and a half. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided by email to facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220314093445

FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005787
ADMINISTRATOR:WILLIAM MARAFACILITY TYPE:
772
ADDRESS:33721 BLUE LANTERNTELEPHONE:
(949) 371-3857
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 0DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jason ShipleyTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Resident pushed other resident while in care
Resident was retaliated against while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Program Director Jason Shipley and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as medication orders and facility notes. Regarding the allegations that resident pushed other resident while in care and resident was retaliated against while in care, the investigation revealed the following: On 02/22/2022, Client 1 was observed to be having an episode of aggressive behavior. C1 shoved aside three clients at the top of the stairs and then fell down the stairs. Clients who were shoved aside did not have any injuries and clients requested to contact law enforcement. Per incident report submitted to the department, OC Sheriff arrived the next day to make a report. Sheriff declined a report due to C1 not intending to harm the other clients. While the clients were pushed by C1, the clients were not injured and C1 was having an episode of aggressive behavior. Four out of four staff deny any knowledge of bullying behavior towards C2. None of the staff were aware of CONTINUED ON LIC 9099C DATED 03/15/23
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 22-AS-20220314093445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005787
VISIT DATE: 03/15/2023
NARRATIVE
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this allegation and deny any bullying occurring. Clients declined to speak with LPA. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the violation occurred.

Exit interview conducted and a copy of this report was emailed to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8