306006262-5-25-2023-22-AS-CGUZ-CS6P62-20230525110139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 05/25/2023
Date Signed: 05/25/2023 11:01:48 AM

Document Has Been Signed on 05/25/2023 11:01 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:	REVIVAL MENTAL HEALTH, LLC		FACILITY NUMBER:	306006262
ADMINISTRATOR:	MICHAELIS, TYLER		FACILITY TYPE:	772
ADDRESS:	9879 HAMILTON AVE		TELEPHONE:	(949) 606-4681
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 0	DATE:	05/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tyler Michaelis		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs met with designated Administrator (AD) Tyler Michaelis and Compliance Officers Wendy Galvan, Laura Hagan, Christina Farschian. An application to operate a Social Rehabilitation Facility (SRF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 11/15/2022. Structure: The facility is a two-story house with three client bedrooms, a medication room, three bathrooms, two living room areas, a kitchen, a dining room area, a laundry room, and attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entryway of the facility. There is a backyard with an exit gate on each side of the house, however only westside exit is designated as an emergency exit. There is a shaded seating area and LPAs did not observe any obstacles or hazards in the backyard. Resident Bedrooms All client bedrooms had the required furnishings. LPAs observed all beds had linens and blankets. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in locked medication room. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept locked in medication room.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REVIVAL MENTAL HEALTH, LLC	FACILITY NUMBER: 306006262
	VISIT DATE: 05/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Fire clearance:
Was approved by a fire inspector of Fountain Valley Fire Department on 04/05/2023. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 111.9 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REVIVAL MENTAL HEALTH, LLC	FACILITY NUMBER: 306006262
	VISIT DATE: 05/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove, oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3