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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005881
Report Date: 12/07/2021
Date Signed: 12/07/2021 12:21:13 PM

Document Has Been Signed on 12/07/2021 12:21 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005881
ADMINISTRATOR:GUASTELLO, TEDFACILITY TYPE:
772
ADDRESS:26065 WATERWHEEL PLACETELEPHONE:
(949) 371-3857
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Dan Robinson, AdministratorTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and LPA explained the nature of the visit. Dan Robinson, Administrator arrived shortly after and me with LPA.

LPA Martinez began the tour of the inside and outside of the facility. There are five clients in care and there are no active covid-19 cases in facility. LPA observed three clients in living room doing a group session and one client having a one on one session. All clients appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap/sanitizer and appeared to be clean. LPA inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. Clients bedrooms are all two shared and one private bedrooms. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies in the facility. LPA toured the outside of the facility and observed a seating area for clients enjoyment. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to the Administrator for their records.

Based on the observation 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 the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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