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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005893
Report Date: 11/02/2022
Date Signed: 11/02/2022 04:11:03 PM

Document Has Been Signed on 11/02/2022 04:11 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:
306005893
ADMINISTRATOR:COKE, BETH PH.DFACILITY TYPE:
772
ADDRESS:28334 PASEO MICHELLETELEPHONE:
(949) 371-3857
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 6DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dan RobinsonTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Dan Robinson. LPA explained the reason for the visit. LPA and Administrator toured the facility. Facility is a single story home with 3 bedrooms, 1 master bedroom which is a therapy room, an office, kitchen, living room, dining room, 4 bathrooms and a 3 car garage that is used for storage. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all client rooms had the required furnishing. LPA observed all bathrooms were clean and operational. LPA observed the fireplaces in the living room, family room and master bedroom are all screened. LPA observed the medications and sharp objects are kept locked in the office. LPA inspected the first aid kit and it had all the required elements. LPA observed the kitchen is clean and organized. LPA and Administrator toured the backyard. LPA observed the pool is fenced and covered. The pool is kept secured and not used by clients. Both exit gates are operational. There is a seating area in the backyard to sit outside. LPA consulted with the Administrator concerning continued Covid-19 mitigation and reporting requirements. No deficiencies observed during today's visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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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