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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:15:20 AM

Document Has Been Signed on 10/31/2022 11:15 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: 1DATE:
10/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marissa Hernandez- Staff TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 10/25/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Marissa Hernandez.

Unusual Incident/Injury Report (LIC 624) was received on 10/25/2022 for an incident that occurred on 10/24/2022. Per LIC 624 Client 1 (C1) requested to be hospitalized due to auditory hallucinations. While transporting C1, C1 became agitated and expressed distaste for Crisis Stabilization Unit (CSU). C1 threatened to elope and took off their seat belt and go out of the car and walked away. Staff called Santa Ana PD and filed a missing persons report.

Per interview with Marissa Hernandez facility protocol is to call local PD and file a missing persons report. C1 was later located and referred to different services.

During the visit LPA reviewed C1's file.

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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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