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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005881
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:06:18 PM

Document Has Been Signed on 12/19/2024 01:06 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005881
ADMINISTRATOR/
DIRECTOR:		GUASTELLO, TEDFACILITY TYPE:
772
ADDRESS:26065 WATERWHEEL PLACETELEPHONE:
(949) 371-3857
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Eric Schlothan, Clinical DirectorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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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 Eric Schlothan, Clinical Director and explained the nature of the visit.

Six clients currently reside at this location, all clients were present at the time of visit. LPA accompanied by a staff member began the tour of the inside and outside of the facility. The facility is a two-story home with three client bedrooms, two client bathrooms, kitchen, dining room, two living rooms, therapy room, med room, staff bathroom, backyard, and an attached garage. Client bedrooms are all located on the second floor and the common spaces are located in the first floor. 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 additional food stored in a freezer and two refrigerators in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in the medication room which is kept locked for inaccessibility to clients in care. Medication room is located on the first floor adjacent to the door of the garage. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care, LPA cross checked medication was accurate according to dosage and date. LPA measured the hot water temperature which measured 118.4 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Facility has two client bathrooms on the second floor and one staff bathroom on the first floor. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in a storage cabinet in the medication room. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 306005881
VISIT DATE: 12/19/2024
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comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Facility has activity supplies including but not limited to: puzzles, games, arts and crafts, exercise equipment and a full activity calendar. Carbon monoxide and smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is several seating areas for client’s enjoyment. Exit gate is unlocked and self-latching. LPA observed several fire extinguishers with service date of September 11, 2024, mounted on the walls throughout the facility. LPA reviewed and verified logs for fire drills. Fire drills conducted monthly, and LPA verified last fire drill was conducted on November 29, 2024. LPA began review of records. Records are kept electronically and were made available to LPA. LPA reviewed three 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.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected 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: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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