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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005813
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:07:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210505162408
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005813
ADMINISTRATOR:NARAINE, KIMBERLYFACILITY TYPE:
772
ADDRESS:26972 VIA BANDERASTELEPHONE:
(949) 313-7444
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 5DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marissa Mara TIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff did not treat client with dignity and respect during their stay at the facility.
Facility did not provide client care and treatment as outlined in the admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation for the allegations listed above. LPA met with Client Coordinator Supervisor Marissa Mara and explained the reason for the visit.

The investigation into the allegation, staff did not treat client with dignity and respect during their stay at the facility, revealed the following. It was alleged that after an incident on 5/2/21 between Client 1 (C1) and Client 2 (C2) staff treated C1 with disrespect and ignored their request to leave the facility and to speak with a family member. The facility reported the incident to the Agency (CCL) on 5/3/21, prior to the complaint being filed. According to the incident report and the staff member interviewed who was present, C1 hit C2. C2 was displaying behaviors that C1 thought were directed toward them but C2 reported to staff that they were not directed toward anyone. No injuries were reported, and law enforcement was not contacted at C2’s request. Staff redirected C1 and C2 and notified other staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20210505162408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005813
VISIT DATE: 12/14/2023
NARRATIVE
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The program director sent additional staff to assist, and the clinical director spoke to C1 and C2. C1 reportedly apologized to C2. Staff reported that after the incident C1 spoke with a family member and informed staff they would be leaving the facility on 5/3/21. Staff interviewed reported that they spoke with C1’s family member and it was agreed C1 would leave the facility at their request on 5/3/21. 4 out of 4 staff interviewed denied the report they disrespected C1 or treated C1 in an inappropriate manner. 4 out of 4 Clients at the facility at the time of the incident declined to be interviewed. C1 could not be reached and was never interviewed. A review of facility records shows C1 was discharged from the facility on 5/3/21. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, facility did not provide resident care and treatment as outlined in the admission agreement, revealed the following. It was alleged Client 1 (C1) did not receive the treatment outlined in the admission agreement and that some sessions were interrupted by other clients. The admission agreement stated that C1 would have the following, weekly individual session therapy with qualified mental health professional, daily group therapy sessions and weekly case management sessions. C1 participated in weekly case management sessions on 4/25/21 and 4/27/21. C1 participated in group sessions each day from 4/26/21 to 5/3/21. C1 participated in individual therapy sessions on 4/27/21 and 5/3/21. C1 participated in a family counseling therapy session on 4/29/21. It was alleged that the care provided did not meet the standards agreed to in the Admission Agreement. No details were provided concerning this aspect of the allegation. C1 could not be reached and was never interviewed. 4 out of 4 clients at the facility declined to be interviewed. 4 out of 4 staff interviewed reported that all clients are treated with respect and cared for in an appropriate manner. No evidence was gathered that could corroborate the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2