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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:41:20 PM

Document Has Been Signed on 01/24/2024 12:41 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
ORANGE COUNTY RO, 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: 6DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Patrick O'ConnellTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Ruth Martinez conducted an unannounced case management visit today. LPA arrived at facility was greeted and granted entry. LPA met with Patrick O'Connell, Program Manager and explained the nature of the visit.

This visit is to follow up on an incident report that was self reported on January 09, 2024, regarding client 1 (C1) incident from January 07, 2024. LPA completed a client file review and interviewed staff. On January 07, 2024, at 9:50pm C1 was observed to be leaving the facility by another staff. C1 was observed to have left in an uber with their belongings. Staff immediately notified the Program Director and the Program Manager, and they immediately called the Fountain Valley Police Department to report the incident. Responsible parties were notified as well. C1 came to the facility of the following night to pick up the rest of their belongings and was discharge out of the program. LPA obtained copies of pertinent documents. Record review reflects facility to have an aftercare plan/discharged instruction form on record.

LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility.

This report was reviewed with the Program Manager and a copy provided and left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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