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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005791
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:09:51 AM

Document Has Been Signed on 07/24/2024 11:09 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005791
ADMINISTRATOR/
DIRECTOR:
JOHNSON, SEANFACILITY TYPE:
772
ADDRESS:26006 CAMPEONTELEPHONE:
(949) 313-7444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 5DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:18 AM
MET WITH:Rey PhillipTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA and staff toured the facility. Facility has 3 bedrooms, 3 bathrooms, living room, dining room, family room, kitchen, staff office, laundry room and a 3 car garage. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguishers are fully charged. LPA observed the client bedrooms have all the required furnishings. The client bathrooms are clean and operational. Hot water measured 109.9 degrees Fahrenheit. There is an emergency evacuation chair at the top of the stairway. LPA observed the fireplace in the family room is screened. LPA observed medications and sharp objects are kept locked in the staff office. LPA and staff toured the backyard and garage. The garage is used for storage and has gaming equipment. The backyard has a shaded patio with seating. No bodies of water observed. The exit gate is latched and self closing. No obstacles or hazards observed in the backyard. LPA reviewed 5 client files and medications, no discrepancies observed. LPA reviewed staff files and training. All direct care staff have the required training and first aid training. LPA inspected the first aid kit. The first aid kit has all the required elements. Clinical Director Rey Phillip arrived during the LPA's visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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