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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:41:02 PM

Document Has Been Signed on 09/28/2022 03:41 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: 2DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lisa Samaan- Program Director TIME COMPLETED:
03:50 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 09/26/2022. 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 09/26/2022 for an incident that occurred on 09/25/2022. Per LIC 624 Client 1 (C1) asked staff 1 (S1) for their phone and wallet. S1 informed C1 of house rules which included not using their cell phone for the first 72 hours at the facility. C1 then left the residence on foot against staff advisement. Facility staff called Tustin Police Department to advise of an elopement from facility, while staff was on the phone with Tustin PD , C1 returned. C1 proceeded to pound on outside gate and kick outside gate causing property damage. Tustin PD arrived and facility provided C1 with their belongings and C1 left.

Per interview with Lisa Samaan, Program Director C1 arrived at facility at 11:45pm on 09/24/2022. The protocol is to have clients meet with therapist for an assessment and have a physical and TB test within the first 24 hours. Due to client leaving within the first 12 hours no Phsycian's Report LIC 602 was completed.

During the visit LPA reviewed House Rules, TAY CRP Contact form, Intake script, Client/Resident Personal Property and Valuables , Admission Agreement and Daily Shift Notes.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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