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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005813
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:03:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/27/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240227090407
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005813
ADMINISTRATOR:WILLIAM MARAFACILITY TYPE:
772
ADDRESS:26972 VIA BANDERASTELEPHONE:
(949) 313-7444
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Anand Mehta- Executive Director/LMFTTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff did not ensure that the facility provides a safe environment for the clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to conduct the 10-day complaint investigation into the above allegation. LPA was allowed entry by Client Coodinator Katilin Kolack and stated the purpose of the visit. Executive Director (ED) / Licensed Marriage and Family Therapist (LMFT) Anand Mehta arrived on premises at 9:47am. On today's visit, LPA observed the front/backyard patio and interviewed two staff. The following was determined:

It is alleged that the staff did not ensure that the facility provides a safe environment for the clients in care. At 9:23am, LPA observed the two potted plants of the Pencil Cacti also known as the Euphorbia Tirucalli in the front patio. None were observed in the backyard. The Pencil Cactus is known to produce a poisonous latex that can cause temporary blindess per the internet research. LPA and ED Mehta observed the Facility Technicians Daniel Parker and Dave Ebbert remove and pick up the Pencil Cacti during the visit at 10:51am.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 3
Control Number 22-AS-20240227090407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005813
VISIT DATE: 03/07/2024
NARRATIVE
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Therefore, based on LPA's observations and interviews, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not ensure that the facility provides a safe environment for the clients in care is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 2. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director/Licensed Marriage and Family Therapist Anand Mehta and a copy of this report including the LIC9099-C, LIC9099-D, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240227090407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005813
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2024
Section Cited
CCR
81072(a)(2)
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81072 Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following: (2) "To be accorded safe, healthful and comfortable accommodations..."
This requirement was not met as evidenced by:
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ED Mehta stated that the (2) plants will be removed during the visit.
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Based on observation and interviews, LPA observed two potted Pencil Cacti (or Euphorbia Tirucalli) in the front patio area which poses a potential Health and Personal Rights risk to persons in care.
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3