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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006082
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:36:56 PM

Document Has Been Signed on 06/21/2023 03:36 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: 3DATE:
06/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Michelle MariscalTIME COMPLETED:
03:55 PM
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LIceninsg Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on incident report regarding Client 1 (C1). LPA was greeted and granted entry by Staff Tina Huang. LPA met with Quality Assurance (QA) Michelle Mariscal and the purpose of the visit was discussed.

Per incident report, on 5/26/23, C1 requested to be discharged and transportation via Uber was pending facility approval. C1 did not want to comply with facility policies and procedures for discharge and decided to leave facility on foot. At the time of the incident, LPA spoke with Administrator (AD) Lisa Samaan who stated C1 took all their belongings except for their medications because they refused. Per AD, C1 also refused to list an emergency contact. Due to C1 refusing to follow facility exit protocol and procedure, a missing person’s report was filed with the Tustin Police Department.

During today’s visit LPA spoke with Staff 1 (S1) who was present during incident, and they confirmed C1 expressed their desire to discharge on 5/26/23 and their therapist was contacted. Therapist met with C1 and was present for C1’s departure. LPA obtained copies of Staff Communication Log dated 5/26/23 and C1's therapist contact information. QA confirmed they would notify the Department regarding updates from Tustin Police Department.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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