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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 05/14/2025
Date Signed: 05/14/2025 11:42:59 AM

Document Has Been Signed on 05/14/2025 11:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:REVIVAL MENTAL HEALTH, LLCFACILITY NUMBER:
306006262
ADMINISTRATOR/
DIRECTOR:		MICHAELIS, TYLERFACILITY TYPE:
772
ADDRESS:9879 HAMILTON AVETELEPHONE:
(949) 606-4681
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
05/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Patrick O'Connell- Program ManagerTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Jessica Cho and Eboni Bentley made an unannounced case management visit for the purpose of following up on an incident report submitted to the Orange County Regional Office on November 14, 2023. LPAs were greeted and granted entry and explained the reason of the visit to Program Manager (PM) Patrick O'Connell.

The facility self-reported an incident of sexual abuse where Staff #1 (S1) was intentionally pursuing an intimate relationship with Client #1 (C1) during their residency at the facility. The incident is as follows: On November 11, 2023, C1, Client #2 (C2), and Client #3 (C3) went to a hair salon for a haircut. C2 and C3 went inside the salon while S1 and C1 stayed behind in the vehicle. It was reported that C2 and C3 witnessed S1 and C1 kissing after their haircut. S1 bribed C2 and C3 not to report and purchased a tall can of beer for C2. After arriving to the facility, C3 reported S1 to management in which S1 made an admission kissing C1 and purchasing alcohol for C2 in order to prevent C2 from reporting what they had witnessed.

On November 16, 2023, the Department conducted an unannounced health and safety check on the clients present and observed no health and safety issues. During the course of the investigation, five clients and six staff interviews were conducted and pertinent records were obtained which includes the Personnel Report, Summary of Discharge, Client House Guidelines, Admission Agreement, Physician's Report, Appraisals, Needs and Services Plans, S1's Resume, Sexual Harassment Policy, Code of Conduct, Employee Confidentiality Agreement, Criminal Records Statement (LIC508), Employment Offer, and Job Description. Two out of the two witness clients confirmed observing the kissing between S1 and C1. S1 also had made an admission during the facility's internal investigation and confirmed kissing C1.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/14/2025 11:42 AM - It Cannot Be Edited


Created By: Jessica Cho On 05/14/2025 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 A
05/15/2025
Section Cited
CCR
81072(a)

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81072 PERSONAL RIGHTS (a) "Each client shall have personal rights which include, but are not limited to, the following..."

This requirement was not met as evidenced by:
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Licensee stated S1 was terminated on 11/12/23 and will retrain and provide proof of in-service training covering the code of conduct, sexual harrassment policies and mandated reporter to LPA via email by POC due date.
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Based on S1's admission and review of records, the licensee did not comply with the section cited above which poses an immediate Safety and/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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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 Per review of S1's records, S1 received all training and signed the Code of Conduct dated July 25, 2023. The code of conduct outlines that staff are to "maintain a professional relationship with all participants" which includes avoiding "conflicts of interest and sexual contact" strictly prohibiting any "intimate of physical relationships between staff and participants." S1 was reported to have been immediately terminated following the incident on November 12, 2023 which was verified on the incident report dated November 13, 2023.

Although facility handled the situation accordingly, it is determined that based on C1's admission and violation of the facility's code of conduct, a violation of the Title 22 was observed. A deficiency is being cited on the attached LIC809D.

An exit interview was conducted with Program Manager Patrick O'Connell, and a copy of this report including the LIC809D, LIC811s, and the appeal rights were provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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