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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 01/24/2022
Date Signed: 01/28/2022 11:06:32 AM

Document Has Been Signed on 01/28/2022 11:06 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: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: 0DATE:
01/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Lisa Samaan, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Kathrina Chin made an announced visit to the facility for the purpose of conducting a pre-Licensing inspection. LPA met with and was granted entry by Administrator, Lisa Samaan. The Facility is a Social Rehabilitation facility.

On October 12, 2021, a fire clearance was granted for six (6) ambulatory clients. The facility is a two story structure with four bedrooms and two and a half bathrooms. There is a two car garage. Rooms are provided with adequate furniture, appropriate linens and adequate storage space. Hallways are kept free from any obstruction or tripping hazard. Bathrooms have fixtures and in good repair. Hot water temperature is tested and is within regulatory requirements. Smoke and Carbon Monoxide alarms were tested to be operational. Fire extinguishers were mounted and charged. Kitchen appeared clutter free. Applicant understands that facility will meet the minimum 2 day perishable and 7 day non-perishable food stocked requirements. Posting requirements were in place. Common areas were provided with adequate furniture in good repair. Medications, records, sharp items and toxic or cleaning supplies will be made inaccessible to clients. Three first aid kits were in place. There is a outdoor canopy/gazebo with outdoor furnitures. No clients were in care during this visit.

An Abbreviated Component III was completed with Applicant. Applicant demonstrated and exhibited a clear concise comprehensive knowledge of medication protocols and documentation.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted with Lisa Samaan, Administrator. Copy of this report will be provided to AD Lisa Samaan, Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: WAYMAKERS TRANSITIONAL AGE YOUTH CRISIS RES PRGRM
FACILITY NUMBER: 306006082
VISIT DATE: 01/24/2022
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SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC809 (FAS) - (06/04)
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