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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005894
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:01:36 PM

Document Has Been Signed on 12/14/2023 03:01 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:
306005894
ADMINISTRATOR:PH.D COKE, BETHFACILITY TYPE:
772
ADDRESS:24171 GRAYSTON DRIVETELEPHONE:
(949) 371-3857
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Dan Robinson, Senior Director of Community RelationsTIME COMPLETED:
03:22 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry by Kaileiy Merino, Client Coordinator II . LPA conducted inspection with CCII, Sydney Sroka, Clinical Quality Liaison, Samual Justice, Facility Supervisor and Dan Robinson, Senior Director of Community Relations.

The facility is a two-story home with three client bedrooms, two bathrooms, kitchen, dining room, living room, therapy room, med room, backyard, and attached two car garage. Two bedrooms, one bathroom and the med room are located on the second floor. LPA observed residents to be participating in group therapy. 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 113.2 degrees Fahrenheit in the common bathroom and 114.4 degrees Fahrenheit in the upstairs bathroom. LPA observed facility has emergency food and water supply stored in the garage. Carbon Monoxide/Smoke Detectors were tested and operational. Fire Extinguishers were fully charged as indicated by the arrow pointing in the green zone. Service tags indicated the extinguishers were last serviced on September 26, 2023. Medication for each resident is kept in the medication room. The backyard has one shaded seating area. 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 three of the six residents files, and 3 staff files. LPA interviewed two staff.

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)
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