306005893-12-9-2025-22-AS-KSGH-DP7SGR-20251209125221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005893
Report Date: 12/09/2025
Date Signed: 12/09/2025 12:52:54 PM

Document Has Been Signed on 12/09/2025 12:52 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 MICHAEL		FACILITY NUMBER:	306005893
ADMINISTRATOR/ DIRECTOR:	COKE, BETH PH.D		FACILITY TYPE:	772
ADDRESS:	28334 PASEO MICHELLE		TELEPHONE:	(949) 371-3857
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 6		CENSUS: 5	DATE:	12/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Kerri Bamper, compliance staff Waylon Georgeson, compliance staff David Asch, Clinical director Kristina Perez, Residential supervisor		TIME VISIT/ INSPECTION COMPLETED:	01:05 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by a facility direct service provider after introducing himself and stating the purpose of the visit. Compliance staff Kerri Bamper was notified and arrived later to assist with the visit along with Clinical Director David Asch and compliance staff Waylon Georgeson. Residential supervisor Kristina Perez also arrived during the visit and assisted. There are currently five ambulatory clients in care. Clients are observed either relaxing in their respective bedrooms, receiving meals and participating in group activities in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with three shared bedrooms used by clients in addition to a medication room, therapy room, laundry room, kitchen and living room. The attached garage is used for storage. There are two shared bathrooms used by clients. All occupied bedrooms appear clean and sanitary. Bathrooms appear clean and sanitary as well. Hot water temperature measured at 108.9F at one of the faucets used for personal grooming. Linen and personal hygiene supplies are verified to be present. All cleaning supplies are stored in a locked cabinet in one of the facility's hallways. The laundry room is locked and used by clients only under staff supervision. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. There are no sharp items in the kitchen as all knives used for cooking are brought by the facility's chef and removed from the premises. Additional sharp items are stored in the same cabinet as the medication central storage located in the staff office/medication room. CONTINUED ON FORM LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 306005893
	VISIT DATE: 12/09/2025

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CONTINUED FROM FORM LIC809
Multiple wall-mounted fire extinguishers are present and verified to be charged, with a maintenance tags dated 2025 attached. Carbon monoxide and smoke detectors are present in each room, hallways and bedrooms and verified to be operational.

LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with outdoor furniture for clients use in the backyard. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. There is a swimming pool on the premises which is verified to be adequately fenced and covered with a safety net. It is not typically used by clients. The facility does not utilize either locked perimeters or delayed egress.

LPA reviewed five client records which were found to include all necessary elements of documentation. LPA reviewed client medication records and prescription orders for all five clients with no discrepancies observed.

LPA reviewed staff records for four staff members scheduled at the facility during the visit. All staff members on the schedule are background cleared and associated. Proof of current CPR training reviewed for all four staff in place. Annual and initial training reviewed and found to be adequate. Disaster drills are conducted monthly for a different shift, which translates into quarterly drills for each shift.

Based on the observatiosn conducted during the present visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC809 (FAS) - (06/04)

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