<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005893
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:58:34 PM

Document Has Been Signed on 12/14/2023 02:58 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 ASC, 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: 4DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dan Robinson, Senior Director of Community RelationsTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility but no one was home. LPA called the phone number on file and got a hold of a staff member. Staff member said someone would arrive at the facility within 15 minutes of the LPA’s call. The chef arrived at the facility and let the LPA in to begin inspection. Sydney Sroka, Clinical Quality Liaison, Samual Justice, Facility Supervisor and Dan Robinson, Senior Director of Community Relations joined the inspection during the tour.

The facility is a one-story home with three client bedrooms, three bathrooms, kitchen, dining room, two living rooms, therapy room, staff office, backyard with pool, and attached two car garage. LPA observed residents to be away from the facility at the time of inspection. Facility appears clean, sanitary and organized. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 113 degrees Fahrenheit in the bathroom in the connected shared rooms, 116.2 degrees Fahrenheit in the bathroom in the shared room and 109 degrees Fahrenheit in the therapy room bathroom. LPA observed facility has emergency food and water supply. Medication for each resident is kept in a locked cabinet in the staff office. The backyard has two shaded seating areas. There is a pool surrounded by a fence with a net on top of the pool. Facility has activity supplies including but not limited to: puzzles, games, arts and crafts, exercise equipment and a full activity calendar. Exit gate is unlocked and self latching. LPA reviewed two of the four residents files, and 3 staff files. LPA also reviewed personnel, client and administrative files for facilities #306005881 and #306005894 since the the SDCR works with all three facilities.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1