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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005805
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:54:50 PM

Document Has Been Signed on 07/18/2024 03:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005805
ADMINISTRATOR/
DIRECTOR:		NARAINE, KIMBERLYFACILITY TYPE:
772
ADDRESS:24262 SUNNYBROOK CIRCLETELEPHONE:
(949) 313-4709
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Christina Kayanan, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting the facility's Required Annual Inspection. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Clinical Director Christina Kayanan, Executive Director arrived later to assist with the visit. During the inspection LPA accompanied by staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:
The facility is a one-story house with three shared 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 faucets and toilets were operational. Water temperature tested to be within the appropriate temperature range. LPA observed all windows were screened and not equipped with security window bars. The back yard has a shaded sitting area equipped with outdoor furniture. LPA observed two staff and five clients present. Clients were observed engaging in group activity when LPA arrived to the facility.

LPA observed and reviewed the facility's 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. Meals are catered by a chef for lunches and dinners. LPA observed the facility does have a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations.

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 three staff members during the visit.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MICHAEL
FACILITY NUMBER: 306005805
VISIT DATE: 07/18/2024
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CONTINUED FROM FORM LIC809
Background clearance, training records, driving records were verified for randomly selected staff members. All staff members present are cleared and associated to the facility.

All five clients were in a clinical group activity upon LPA's arrival to the facility. Three of them moved on to another group activity during the visit and were observed to be actively participating while two other clients were observed to be resting in their respective bedrooms.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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