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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:28:43 PM

Document Has Been Signed on 12/29/2022 03:28 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WAYMAKERS TRANSITIONAL AGE YOUTH CRISIS RES PRGRMFACILITY NUMBER:
306006082
ADMINISTRATOR:SAMAAN, LISAFACILITY TYPE:
772
ADDRESS:17332 AMAGANSET WAYTELEPHONE:
(949) 410-0467
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 1DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lisa Samman - Program Director TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 12/08/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Program Director Lisa Samaan.

Unusual Incident/Injury Report (LIC 624) was received on 12/08/2022 for an incident that occurred on 12/07/2022. Per LIC 624 Client 1 (C1) left facility at 11:56pm. Staff called Tustin PD and they arrived at 1:20am, staff filed a missing persons report. At 2:01AM C1 returned to facility and staff was notified by Program Director to not allow C1 back into facility. Staff contacted C1's responsible party and responsible party stated would be unable to pick up C1. C1 was offered their belongings but declined, facility offered warm clothing and C1 accepted.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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Document Has Been Signed on 12/29/2022 03:28 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 12/29/2022 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WAYMAKERS TRANSITIONAL AGE YOUTH CRISIS RES PRGRM
FACILITY NUMBER: 306006082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/04/2023
Section Cited
CCR
81068.5(b)(1)

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Eviction Procedures (b) The licensee shall be permitted to evict a client with three days' prior written notice provided that both of the following requirements have been met:
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Licensee to update eviction policy and provide to LPA by POC due date.
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(1) The licensee has received prior written and/or documented telephone approval for the notice of eviction from the licensing agency.
This was not met as evidence by, facility staff would not allow client back into facility after elopment.
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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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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