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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005893
Report Date: 10/26/2023
Date Signed: 10/26/2023 02:25:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/24/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231024110227
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005893
ADMINISTRATOR:COKE, BETH PH.DFACILITY TYPE:
772
ADDRESS:28334 PASEO MICHELLETELEPHONE:
(949) 371-3857
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 5DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dan RobinsonTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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insufficient staffing to meet clients needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Program Director Dan Robinson and explained the reason for the visit. The investigation revealed the following. It was alleged that the facility only had one staff member scheduled on August 5th 2023 between 6:30 am until Monday August 7th 2023 and on Saturday August 12 2023 from 3:00pm until 6:30 am the next day and on Sunday August 13th from 3:00 pm until 6:30 am the next day. LPA interviewed the Program Director who verified this information. LPA reviewed the facility schedule which verified the report. According California Code of Regulations Title 22, Division 6, Chapter 2, 81065.5 (a)(3) All facilities shall employ staff and have staffing patterns and ratios as indicated on the facility certification document. The facility is licensed and certified as a Transitional Residential Treatment Program, which means according to regulation listed above, they must comply with Title IX, section 531(b)(2) which states, "... There shall be a staffing ratio of at least one (1) full-time equivalent direct service staff for each 2.5 clients served.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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-20231024110227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MICHAEL
FACILITY NUMBER: 306005893
VISIT DATE: 10/26/2023
NARRATIVE
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All scheduled hours in the facility shall be considered part of this required full-time equivalent staffing ratio.".

Based on the information gathered through interviews and document review the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 2. An exit interview was conducted and a copy of this report (LIC 809, LIC 809D) along with appeal rights was provided to the facility representative.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20231024110227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MICHAEL
FACILITY NUMBER: 306005893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
81065.5(a)(3)
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All facilities shall employ staff and have staffing patterns and ratios as indicated on the facility certification document. This requirement was not met as evidenced by the interview with the Program Director and the facility schedule which shows there was only one staff member on,
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Licensee agrees to have adequate staffing of all shifts to meet the regulatory requirements for the facility type. Licensee agrees to forward copies of the facility schedule and hours worked by staff to verify the requirement is being met. Licensee to forward proof to LPA by 11/3/23.
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August 5th 2023 between 6:30 am until Monday August 7th 2023 and on Saturday August 12 2023 from 3:00pm until 6:30 am the next day and on Sunday August 13th from 3:00 pm until 6:30 am the next day. This poses an immediate safety and health risk to clients 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: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3