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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005805
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:45:32 PM

Document Has Been Signed on 08/01/2023 02:45 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: 5DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Abby Huffnagle
Dan Robinson		TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Abby Huffnagle, and LPA discussed the purpose of the inspection. Program Manager (PM) Axel Vargas arrived at 10:30 a.m. and Program Director Dan Robinson arrived at 11:00 a.m.

During the inspection LPA and Staff Huffnagle conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms, a therapy room, a medication room, and two bathrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets.Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 108.6-113.1 F degrees. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and five clients present. Clients were observed engaging in group activities in the morning, and after lunch staff took clients to an off-site gym class.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility does not have a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations; a Deficiency was cited on today’s date. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed to be kept locked and inaccessible. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are also inaccessible to clients. Medication cabinet was observed to be locked in medication room. LPA reviewed five client files and three staff files. LPA interviewed five clients and one staff. (Cont. LIC809-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 306005805
VISIT DATE: 08/01/2023
NARRATIVE
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Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2023 02:45 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 08/01/2023 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A MISSION FOR MICHAEL
FACILITY NUMBER: 306005805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81076
(d) The Licensee shall meet the following storage requirements (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and client interviews, the licensee did not comply with the section cited above as three out of five clients reported there is insufficient food, and LPA did not observe a two day supply of perishable food on hand, which poses an immediate health, and personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Program Director (PD) stated that Tuesday afternoon food is delivered and would be delivered later today. PD will provide meeting minutes to all facility staff via email to notify staff that a minimum of 7-day non-perishable and 2-day perishable is to be maintained at all times. Program Manager will provide LPA with picture proof of food delivered this afternoon and maintian inventory twice a week to ensure regulation is met.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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