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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005791
Report Date: 07/26/2022
Date Signed: 07/26/2022 01:56:46 PM

Document Has Been Signed on 07/26/2022 01:56 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:
306005791
ADMINISTRATOR:JOHNSON, SEANFACILITY TYPE:
772
ADDRESS:26006 CAMPEONTELEPHONE:
(949) 313-7444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 3DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Melanie Mitrovich, Dan RobinsonTIME COMPLETED:
02:04 PM
NARRATIVE
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:Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA explained the reason for the visit. During the visit Program Director Dan Robinson arrived. LPA and the Program Director toured the facility. LPA observed the sign in station near the facility entrance. LPA observed the PUB 475 poster posted next to the entrance. The facility is a two story house with a living room, dining room, family room (with a screened fireplace), kitchen, staff office (downstairs), 3 car garage (used for storage), 3 bedrooms and 3 bathrooms. LPA observed board games and books stored on a bookcase in the dining room. LPA observed the kitchen is clean and organized. LPA observed a small amount of water/moisture under the dishwasher. LPA and the Program Director toured the outside of the facility. No bodies of water observed in the backyard. Both exit gates are operational. There is a covered patio with a sitting area for clients. No obstacles or hazards observed in the backyard. LPA observed all fire extinguishers are fully charged. Hot water measured 109.4 degrees Fahrenheit. LPA inspected the First Aid Kit, the First Aid Kit had all the required elements. LPA consulted with the Program Director concerning continued Covid-19 mitigation and reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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