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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006143
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:10:04 AM

Document Has Been Signed on 12/29/2022 11:10 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:MENTAL HEALTH COLLECTIVE, THEFACILITY NUMBER:
306006143
ADMINISTRATOR:ROSENBAUM, GREGORYFACILITY TYPE:
772
ADDRESS:519 SANTA ANA AVE.TELEPHONE:
(888) 717-9555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 1DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ruby Leyva - Mental Health Tech, Gregory Rosenbaum- Administrator TIME COMPLETED:
11:20 AM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit due to an incident reported on 12/13/2022. LPA was greeted and granted entry into the facility by Ruby Leyva, Mental Health Technician. Administrator Gregory Rosenbaum arrived at 10:20 AM.

The department received an Unusual/Serious Injury Incident reported dated 12/13/2022 for an incident that occurred on 12/11/2022. It was reported that Client 1 (C1) checked out a razor to shave themselves. C1 reported that they had cut themselves on their face and finger, C1 was given a Band-Aid and ointment. C1 requested another razor to finish shaving, sometime later C1 reported that they had made horizontal cuts to their forearms. C1 reported they did not have suicidal ideations. Facility Nurse performed a body check and noted no other cuts were made. Clinical assessment was performed on C1 and it was determined no other preventative actions needed.

Per Administrator Gregory Rosenbaum, C1 was placed on 15 minute checks and staff searched C1's room for other sharps. C1 successfully discharged out of the program on 12/22/2022.

During the visit LPA reviewed and obtained copies of Admission Agreement, Initial Psychiatric Evaluation dated 09/26/2022 and copies of body check consent form.

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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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