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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 12/13/2022
Date Signed: 12/13/2022 02:36:54 PM

Document Has Been Signed on 12/13/2022 02:36 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: 0DATE:
12/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jordan Aguayo- House Supervisor TIME COMPLETED:
02:50 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 12/08/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to House Supervisor Jordan Aguayo.

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.

Per interview with Jordan Aguayo, C1 arrived at facility on 12/07/2022 at 2:45PM. C1 came into the facility and staff attempted to do initial intake, based on C1's behavior facility decided C1 should fill out additional paperwork the next day.
Based on interview with Jordan Aguayo facility has spoken with C1's responsible party and C1 is currently residing with them.

During the visit LPA reviewed Client Initiated Discharge Agreement, Client Personal Property and Valuables, and Consent for Emergency Medical Treatment.

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: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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