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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005813
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:08:34 AM

Document Has Been Signed on 03/07/2024 11:08 AM - 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:
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
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Anand Mehta- Executive Director/LMFTTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings for the 10-day complaint investigation for Complaint Control Number: 22-AS-20240227090407. LPA met with Executive Director (ED)/Licensed Marriage and Family Therapist (LMFT) Anand Mehta and stated the purpose of the visit.

*Deficiency cited Title 22 Regulation 81072(a)(2) "To be accorded safe, healthful and comfortable accommodations..." LPA observed the two potted Pencil Cacti (also known as the Euphorbia Tirucalli) were removed at during the complaint investigation conducted on March 7, 2024 at 10:51am.

The ED/LMFT Anand Mehta has complied with the POC for the item cited on March 7, 2024.

An exit interview was conducted with Executive Director/Licensed Marriage and Family Therapist Anand Mehta, and a copy of this report including the Letter of Deficiency Citations Cleared 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
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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