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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:23:32 PM

Document Has Been Signed on 11/16/2023 02:23 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: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:
11/16/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Trevor SlaneyTIME COMPLETED:
02:38 PM
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This unannounced Case Management – Health Checks inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check. LPA met with Program Director (PD) Trevor Slaney and explained the purpose of the inspection.

During the inspection, LPA and PD toured the facility. LPA observed there were 4 staff and 1 client present. LPA conducted a health and safety check on the client present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA requested and reviewed copies of the resident roster, staff roster, resident files, and staff files.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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