<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006469
Report Date: 08/02/2024
Date Signed: 08/02/2024 09:49:46 AM

Document Has Been Signed on 08/02/2024 09:49 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:
306006469
ADMINISTRATOR/
DIRECTOR:		MICHAELIS, TYLERFACILITY TYPE:
772
ADDRESS:16252 MAGELLAN LNTELEPHONE:
(949) 606-4681
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 0DATE:
08/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:35 AM
MET WITH:Compliance Manager Laura HaganTIME VISIT/
INSPECTION COMPLETED:
10:15 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 Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a two story residential home. LPA along with Compliance Manager Laura Hagan toured facility at 7:49 AM and observed the following:

Fire clearance approval was received on 07/10/24. Structure: Facility is a two story, five bedroom (three shared Client bedrooms and two staff offices) 3 bathroom house with attached garage. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All clients bedrooms meet Licensing requirements. Bathrooms: All bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Facility has three Fire extinguishers which are mounted and charged. Appliances: Gas Stove and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area inside garage. Water Temperature: Tested and recorded between 107.6 to 116.0 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has games available. Medications, First-Aid Kit & Book: Facility has three first aid kits present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating. Facility has a Inaccessible pool with a secured fence and pool cover.

CONTINUED ON 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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 2
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: 306006469
VISIT DATE: 08/02/2024
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
Administrator's Certificate observed as expiring August 8, 2024.

Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating other facilities.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.

An exit interview was conducted with Compliance Manager and Administrator. A copy of report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2