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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005894
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:11:23 AM

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 Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231024111758
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005894
ADMINISTRATOR:PH.D COKE, BETHFACILITY TYPE:
772
ADDRESS:24171 GRAYSTON DRIVETELEPHONE:
(949) 371-3857
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Program Director - Dan RobinsonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Insufficient staffing to meet clients needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Dan Robsinson.

It was alleged that facility has insufficient staffing to meet clients needs.

Per documentation review, it was verified that there was only one staff member who was scheduled on August 5, 2023 for the 6:30AM-3:00PM shift, August 6, 2023, for the 2:30PM-11:00PM shift, and 11:00PM-7:00AM shift, August 12, 2023 for the 2:30PM-11:00PM shift, and August 13, 2023 for the 6:30AM-3:00PM shift, 2:30PM-11:00PM shift and 11:00PM-7:00AM shift. LPA De Perio conducted an interview with the facility program director who confirmed this information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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-20231024111758
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: 306005894
VISIT DATE: 01/23/2024
NARRATIVE
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According to the 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, facility 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. All scheduled hours in the facility shall be considered part of this required full-time equivalent staffing ratio.".

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.

For this visit, deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 2.

An exit interview was conducted with AD Robsinson.

A copy of this report was explained, and appeal rights were provided during the visit.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20231024111758
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: 306005894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2024
Section Cited
CCR
81065.5(a)(3)
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81065.5 Day Staff-Client Ratio
(a) ...Sufficient direct care staff are at the facility whenever clients are present.
(3) ...Employ staff...as indicated on the facility certification document.
This requirement is not met as evidence by:
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As a plan of correction (POC) licensee agrees for all shifts to meet the regulatory requirements for the facility type. Licensee will provide proof of the schedule, showing the hours and shifts worked by staff. Licensee will provide proof to LPA on or by 01/24/24.
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Based on interviews conducted, and review of documents, it was verified by the facility administrator that on 8/5/23, 8/6/23, 8/12/23, and 8/13/23, there was only one staff member present. This poses an immediate health and safety 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: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3