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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:59:39 PM

Document Has Been Signed on 03/27/2023 01:59 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
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: DATE:
03/27/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michaelis, TylerTIME COMPLETED:
01:30 PM
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Facility Type: SRF
Application Type: Initial
Capacity: 6
Interview Method: Telephone interview

On 3/27/2023, applicant/administrator participated in COMP II for the below pending facilities: Revival Mental Health LLC/306006262 and Revival Mental Health LLC /306006319. Identification of the applicant / administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Nicole Rouse
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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