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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005813
Report Date: 06/30/2023
Date Signed: 06/30/2023 12:47:30 PM

Document Has Been Signed on 06/30/2023 12:47 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ethan Salter, Client Coordinator
Dan Robinson, Program Director		TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for completing a required annual inspection. LPA arrived at facility was greeted and granted entry by staff. LPA met with Ethan Salter, Client Coordinator and explained the nature of the visit. Dan Robinson, Program Director arrived shortly after and met with LPA.

Five clients currently reside at this location, all clients were present at the time of visit. LPA accompanied by Client Coordinator began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is an additional refrigerator in garage for excess food storage. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a locked storage closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected facility bathrooms and LPA measured the hot water temperature which measured 109.2 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored in the garage in a locked cabinet. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A MISSION FOR MICHAEL
FACILITY NUMBER: 306005813
VISIT DATE: 06/30/2023
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operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is seating areas for client’s enjoyment. LPA observed several fire extinguishers with service date of September 21, 2022, mounted on the walls throughout the facility. Fire drills are conducted quarterly and LPA verified last fire drill was conducted June 27, 2023. LPA began review of records. Records are kept electronically and were made available to LPA. LPA reviewed five clients’ records. All the required documentation was present and current in client’s files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representatives and a copy of this report was provided and left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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