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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006262
Report Date: 06/03/2025
Date Signed: 06/03/2025 07:40:21 PM

Document Has Been Signed on 06/03/2025 07:40 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/
DIRECTOR:		MICHAELIS, TYLERFACILITY TYPE:
772
ADDRESS:9879 HAMILTON AVETELEPHONE:
(949) 606-4681
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
06/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Program Director - Trevor SlaneyTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On June 3, 2025 at 2:20pm, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility to conduct an unannounced required 1-Year annual visit using the CARE Inspection Tool. LPA announced self and stated the purpose of the visit to Program Director (PD) Trevor Slaney and was greeted and granted entry. Program Manager (PM) Patrick O’Connell also joined us and was present throughout the visit to assist with the inspection.

This is a Social Rehabilitation Facility (SRF) licensed for a capacity of six ambulatory clients. 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.

During today’s visit, LPA observed six clients present and five staff on duty. LPA obtained copies of pertinent documents for clients and staff, including facility records: client/staff rosters, Personnel Record (LIC500), client and staff records.

LPA conducted a tour of the facility with PD Slaney and observed no imminent health and safety issues. During the visit, LPA toured the interior and exterior of the physical plant with PD Slaney and the following was observed: All mandated posters were posted near the entrance. There were no bodies of water or obstructions on the premises. There is a backyard with an exit gate designated as an emergency exit. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

CONTINUE TO LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2025
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 06/03/2025 07:40 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/03/2025 at 04:53 PM
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: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2025
Section Cited
CCR
80088(e)(1)

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(e) Faucets used by clients... shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically ... not less than 105 degrees F ... and not more than 120 degrees F.
This requirement is not met as evidenced by:
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Licensee will obtain the correct temperature gauge and maintain a temperature log testing temperatures every two hours from 5pm on June 3, 2025 to 5pm June 4, 2025. Licensee stated they will submit water temperature logs to CCLD via email to eboni.bentley@dss.ca.gov by 5pm on POC due date of June 4, 2025.
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Based on observation, the licensee did not comply with the section cited above in three out of three bathrooms, which poses an immediate health and safety risk to persons in care. Water temperatures tested between 121.8 degrees F and 124.5 degrees F.
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Type B
06/11/2025
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... maintenance services ....for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee to fix stove top burner and provide proof to CCLD via email to eboni.bentley@dss.ca.gov POC due date of June 11, 2025.
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Based on observation, the licensee did not comply with the section cited above in one out of five stove burners,which poses a potential health and safety risk to residents in care. LPA observed one burner on the stovetop was not operational during visit.
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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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


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: 06/03/2025
NARRATIVE
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LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharps objects were stored and locked. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available.
There is a two car garage with a refrigerator and additional supply of perishable items. The washer and dryer were observed to be in working condition. Facility has a sufficient amount of emergency food supply and water supply.

All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature of 71 degrees F was maintained throughout the facility. Bathrooms were found to be clean and operational. The water temperatures measured at 121.8 degrees F in Bathroom #1, 123.9 degrees F in Bathroom #2 and 124.5 degrees F in Bathroom #3. A deficiency is being cited.

First aid kit is maintained and contains all the necessary elements and additional items were ordered during the visit. Smoke and carbon monoxide alarms were tested and observed operational. A working telephone (657-301-2061) remains available, and the facility has a device that can be used for video teleconference purposes. The facility has three (3) fire extinguisher that were charged and mounted, all last serviced on April 1, 2025. Liability Insurance is effective March 17, 2025 through March 17, 2026.

Based on today’s observations, deficiencies were cited during this visit as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, deficiency pages, and appeal rights were provided to Program Director (PD) Trevor Slaney.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC809 (FAS) - (06/04)
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