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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881521
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:55:14 PM

Document Has Been Signed on 04/03/2024 12:55 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
371881521
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		MARA, WILLIAMFACILITY TYPE:
772
ADDRESS:3875 PEONY DRIVETELEPHONE:
(949) 313-4709
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:ADMINISTRATOR, WILLIAM MARATIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
12:58 PM
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On April 3, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a Pre-Licensing visit. LPA Mixson met with the Administrator, William Mara, and his administrative team, introduced herself, and stated the purpose of the visit.

The location is a two-story home located at 3875, Fallbrook, CA. 92028 and has three bedrooms, three full bathrooms, a living room, dining room, and a kitchen, with a two-car garage. A backyard and front yard. The North County Fire Protection District approved this facility for six Ambulatory residents, on 02/04/2024. The Facility has a first aid kit and manual, the Administrator has received First Aid and CPR training, and the Administrator’s certificate is current. LPA Mixson observed where medications are to be stored, locked, and inaccessible to the residents. The home is equipped with lights in the passages and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were observed and are operable. LPA Mixson observed the fire extinguisher, it was charged and in the green, it was last checked 04/02/2024.

The cleaning supplies were locked and inaccessible to the future residents, along with the sharp objects and there were no firearms on the premises, as stated by the Administrator currently. The knives were locked in a kitchen drawer, adequate supply of pots, pans, and other kitchen accessories. The facility has the required seven-day supply of non-perishable food items and the two-day supply of perishable food items. LPA Mixson observed hygiene supplies for residents.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A MISSION FOR MICHAEL
FACILITY NUMBER: 371881521
VISIT DATE: 04/03/2024
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 CONTINUED
All doors and passageways were clear of obstruction and free of debris currently at the time of this visit. The fireplace was covered with a screen. There was enough clean linen and hygiene items, and there was appropriate lighting in each of the bedrooms. The bedrooms had the required furnishings for the type of facility being licensed Social Rehabilitation (772).

LPA Mixson observed central heating and air conditioning systems, and they were operable presently at the time of this visit. The Administrator dialed the land line phone number (760) 783-5402, and it was operable. Outside/Yards: Had shade and covering for shaded visits, and activities at the time of this visit. There were no obstructions observed to the walkways and entry and exit ways. The Administrator informed the LPA there were no firearms, and/or ammunition on the premises at this time.

There was a swimming pool on the premises, and it was locked and in accessible to the future residents, the fireplaces were covered with screen and gas supply capped. There was enough clean linen and hygiene items, and there was appropriate lighting in each room and throughout the overall facility. LPA Mixson observed activity rooms and rooms that shall be utilized for groups and therapy sessions.

The Administrated informed the LPA that the Facility vehicle was registered, contained a first aid kit and the facility staff scheduled to drive the vehicle are licensed, insured, and training shall be provided.

The Administrator discussed the process for identifying any individual served who may have special needs, the evacuation process and the current certification process for the Administrator, for this type of facility being licensed today (Social Rehabilitation) 772.

CAB 8.0 Pre-licensing / COMP III to be scheduled, at the Riverside Regional Office, Located at 1650 Spruce Street Riverside, CA.

An exit interview was conducted, a copy of this report was provided to the Administrator, William Mara.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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