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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006262
Report Date: 05/14/2025
Date Signed: 05/14/2025 04:47:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2025 and conducted by Evaluator Eboni Bentley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250507160906
FACILITY NAME:REVIVAL MENTAL HEALTH, LLCFACILITY NUMBER:
306006262
ADMINISTRATOR:MICHAELIS, TYLERFACILITY TYPE:
772
ADDRESS:9879 HAMILTON AVETELEPHONE:
(949) 606-4681
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Program Manager - Patrick O'ConnellTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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The needs and services plan is incomplete.
The facility did not follow their plan of operation.
INVESTIGATION FINDINGS:
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On this date, Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived unannounced to conduct the complaint investigation visit into the above allegations. LPAs announced self and stated the purpose of the visit to Therapist Hayle Bender. Program Manager (PM) Patrick O’Connell later arrived and remained throughout the visit to assist with the investigation.

During today’s visit, LPAs observed three clients present and five staff on duty. LPAs conducted a tour of the facility with PM O’Connell and observed no imminent health and safety issues. LPAs obtained copies of pertinent documents for three (3) clients including facility records: client/staff rosters, Personnel Record (LIC500), the needs and services/treatment plan, discharge plans, and Policy and Procedures Manual. The following was determined based on the review of records:

CONTINUE TO 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20250507160906
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REVIVAL MENTAL HEALTH, LLC
FACILITY NUMBER: 306006262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
81068.3(b)
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81068.3 Modifications to Needs and Services Plan (b) “The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy…”
This requirement was not met as evidenced by:
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Licensee stated that proof of the amended needs and services plan for C1, C2, and C3, and a written Acknowledgement of Understanding of the said deficiency will be submitted to LPA via email by POC due date.
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Based on record review, the licensee did not document the length of stay on the needs and services plan (master treatment plan) in three out of three client records reviewed which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.
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Type B
05/21/2025
Section Cited
CCR
81022(j)
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81022 Plan of Operation (j) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so.
This requirement was not met as evidenced by:
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Licensee stated that proof of amended discharge summaries for C1 and C4, and a written Acknowledgment of Understanding of the said deficiency will be submitted to LPA via email by POC due date.
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Based on record review, the licensee did not follow the plan of operation by not providing evidence of complete referrals for follow up in review of two out of two discharge summaries for C1 and C4 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 22-AS-20250507160906
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: REVIVAL MENTAL HEALTH, LLC
FACILITY NUMBER: 306006262
VISIT DATE: 05/14/2025
NARRATIVE
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It is alleged that the needs and services is incomplete. Per record review, LPAs observed the needs and services plan (Master Treatment Plans) for Clients #1, #2, and #3 did not include an anticipated length of stay, therefore it is determined that the needs and services is incomplete.

It is alleged that the facility is not following their plan of operation. Per record review, LPAs observed that the discharge plan for Clients #1 and #4 did not include referrals, address, phone number, appointment times or dates for follow up. Therefore, it is determined that the facility did not follow the plan of operation as per page 20 of the Policy and Procedures Manual which notes that the discharge summary will include “referral follow-up plans.”

Based on the information gathered during the investigation through record review, the preponderance of evidence standard has been met for the allegations: The needs and services plan is incomplete and Facility is not following their plan of operation are deemed SUBSTANTIATED. Deficiencies are being cited as per the Title 22, Division 6, Chapter 2 of the California Code of Regulations. See the attached LIC9099-D.

An exit interview was conducted with Program Manager Patrick O'Connell, and a copy of this report including the LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7