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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005805
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:01:55 PM

Document Has Been Signed on 06/28/2022 03:01 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:
306005805
ADMINISTRATOR:NARAINE, KIMBERLYFACILITY TYPE:
772
ADDRESS:24262 SUNNYBROOK CIRCLETELEPHONE:
(949) 313-4709
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 2DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Alina Abeschyan and Dan RobinsonTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Care Coordinator Alina Abeschyan. Program Manager Christina Gomez and Client Coordinator Annabelle D'Eliscu were present as well. Program Director Dan Robinson arrived during the visit.

At 9:40 AM, LPA toured the facility with Care Coordinator Annabelle D'Eliscu. Facility has 2 clients in care during today's visit. LPA observed clients in the facility relaxing. All clients appeared happy and well taken care of. Facility appears clean and sanitary. All client's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are currently single occupancy. Facility screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes client temperatures daily. Facility has covid precaution postings as well as all required department postings. Facility submitted mitigation plan to the department and the plan has been approved. LPA observed the emergency disaster plan posted in facility. LPA observed emergency food and water as well as the first aid kit which contained all required items. Facility has ample food supplies and meals are catered. LPA toured the outside grounds and observed a shaded outside visitation area as well as a gardening area. LPA observed the exit gate is self latching and unlocked. Fire extinguishers are mounted and charged. Smoke/ carbon monoxide detectors tested operational during today's visit. LPA observed the locked medication storage area. Facility has gloves, gowns and N95 masks as well as cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation.

During the visit, LPA consulted with Program Director on the importance of maintaining a sufficient supply of emergency food on-site at all times.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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