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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881276
Report Date: 09/11/2023
Date Signed: 09/11/2023 09:21:10 AM


Document Has Been Signed on 09/11/2023 09:21 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MISSION COMMONSFACILITY NUMBER:
361881276
ADMINISTRATOR:THOMAS TAYLORFACILITY TYPE:
740
ADDRESS:10 TERRACINA BOULEVARDTELEPHONE:
(909) 793-8691
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:59CENSUS: 125DATE:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH: Jacquelyn McDonald-Office Manager TIME COMPLETED:
09:30 AM
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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a case management confirmation of removal order. LPA met with Jacquelyn McDonald and she informed of the purpose of the visit.

Today's visit was to deliver an Immediate Exclusion letter for an individual staff 1 (S1) to the licensee. The exclusion of Staff 1 (S1) is based on a complaint of conduct inimical that has been substantiated.

LPA reviewed the exclusion letter with Jacquelyn McDonald, explaining that staff 1 is not allowed to be present in the facility. Jacquelyn understands this Immediate Exclusion and has agreed that S1 cannot be allowed to work and/or live in a CCL Licensed facility and have contact with clients in any facility licensed by the California Department of Social Services.

Based on evidence obtained during today's visit, The LPA has verified the individual is not present, employed or residing at the facility. LPA has advised Jacquelyn to disassociate the individual from their roster and submit an updated LIC500.

An exit interview was conducted, and this report was discussed, and a copy was provided to Jacquelyn McDonald at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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