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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005787
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:00:57 PM

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
11/03/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231103135557
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: 5DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dan RobinsonTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed and staff and clients. Regarding the allegation that facility is in disrepair, the investigation revealed the following: LPA toured the facility during the visit. LPA observed cooling fans are operational. Facility does not have air conditioning due to proximity to the ocean. LPA confirmed washer and dryer need to be repaired and the dishwasher is non-operational. 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 with facility representative and a copy of this report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
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 5
Control Number 22-AS-20231103135557
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: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2023
Section Cited
CCR
81087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This req is not being met as evidenced by:
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Licensee to repair noted items and forward proof to LPA by POC due date.
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Based on interviews conducted and observation, Licensee failed to ensure facility is in good repair. Facility washer/ dryer needs repair and dishwasher is inoperable. This poses a potential 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: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/03/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231103135557

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: 5DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dan RobinsonTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff violated resident’s personal rights
Staff withheld resident’s personal belongings
Staff did not meet resident’s mental health needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and clients as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegations that staff violated resident’s personal rights, staff withheld resident’s personal belongings, and staff did not meet resident’s mental health needs, the investigation revealed the following: Four out of four clients interviewed confirmed knowledge of smoking policy. LPA reviewed C1's cigarette log indicating client has been receiving cigarettes as requested. Facility allows TV/ radio in the evening hours after the day program has been concluded and clients confirmed this. Facility has a pair of headphones that clients can use for 30 minutes at a time. All clients interviewed confirmed availability of headphones for use. TV/ radio is permitted until bedtime at approximately 10:30 PM. C1 stated admitting at the facility without any electronics or headphones besides a cell phone CONTINUED ON LIC 9099C DATED 11/07/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231103135557
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: 11/07/2023
NARRATIVE
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Facility records indicate Client has met with the client's case manager on 10/30/2023 and with the therapist multiple times. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report was provided..
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5