306005894-12-1-2022-22-AS-CDPO-CLPR8B-20221201114741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005894
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:48:15 AM

Document Has Been Signed on 12/01/2022 11:48 AM - 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 MICHAEL		FACILITY NUMBER:	306005894
ADMINISTRATOR:	PH.D COKE, BETH		FACILITY TYPE:	772
ADDRESS:	24171 GRAYSTON DRIVE		TELEPHONE:	(949) 371-3857
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 6	DATE:	12/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Program Director-Dan Robinson		TIME COMPLETED:	12:10 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 3 staff were on duty, who contacted Program Director (PD) Dan Robinson about visit. As of 12/1/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed at the main entrance of the facility. LPA De Perio observed administrator (AD) information for Ted Guastello via file review, who became the designated AD for facility on 1/13/21.

LPA De Perio toured the interior and exterior portions of the facility with staff on duty (S1). The facility is a two level structure and is licensed to be a transitional residential treatment center for 6 clients. Currently, there are a total of 6 clients in care. On the first floor, there is a total 1 shared bedroom for client use, and on the second level, there are a total of two shared bedrooms for clients. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational. Water temperature in restrooms were measured at 110.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care and is located in a locked safe in the staff room. Fire extinguisher was charged, mounted and located in the kitchen and in the living room hallway. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance of the facility. Facility had back-up emergency food and water supply, located in the garage.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/01/2022

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are two gates in the backyard of which only one is utilized as an exit, and was observed to be self-closing and self-latching.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the staff room and in the garage. Medications were locked in the staff room and is made inaccessible to clients in care. Toxins were also observed to be locked and located in the garage and is made inaccessible to clients in care. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with PD Robinson. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio discussed with PD Robinson to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 85075.4 Observation of the Client and Sections 80061 and 85061 Reporting Requirements with PD Robsinson.

LPA De Perio advised PD Robsinson to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with PD Robsinson and a copy of this report, and copies of the regulations discussed were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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