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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005893
Report Date: 05/30/2025
Date Signed: 05/30/2025 02:59:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/23/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250523154545
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:
05/30/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Eric SchlothanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility gave client the wrong medication
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 met with Clinical Director Eric Schlothan and explained the reason for the visit. LPA toured the facility. LPA interviewed staff and clients. LPA reviewed client files and medication administration records. LPA requested documents such as staff roster, client roster, medication administration records and physician reports. The investigation into the allegation revealed the following. It was alleged that Client 1 (C1) was given the wrong medication during the evening medication pass on May 7, 2025. C1 was accidentally given PRN Propranolol 20mg even though it was not requested. C1 reported they did not request the Propranolol and didn't realize it was the wrong medication until they already swallowed it. Staff 1 (S1) verified they gave C1 the Propranolol tablet even though they did not request it. The medication was logged on the Medication Administration Record (MAR) as being administered. S1 reported they didn't realize they gave the wrong pill to C1 until after they swallowed it.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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-20250523154545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005893
VISIT DATE: 05/30/2025
NARRATIVE
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Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250523154545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 306005893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2025
Section Cited
CCR
81075(b)(5)(B)
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Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by,
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Licensee agrees to train staff on medication administration and personal rights of clients (CCR 81075 & 81072). Licensee to forward proof of staff training to LPA.
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Staff 1 reported they gave the wrong medication, Propranolol 20mg, to C1 even though it was not requested. This poses an immediate health, safety and personal rights 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3