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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881522
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:20:04 AM

Document Has Been Signed on 04/03/2024 11:20 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
RIVERSIDE, CA 92507
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
371881522
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		MARA, WILLIAMFACILITY TYPE:
772
ADDRESS:197 NORTH RIDGE DRIVETELEPHONE:
(949) 313-4709
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:ADMINISTRATOR, WILLIAM MARATIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
11:23 AM
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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 197 North Ridge Drive, Fallbrook, CA. 92028 and has three bedrooms, four full bathrooms, a living room, dining room, and a kitchen, with a two-car garage, and 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 will 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 extinguishers, they were charged and in the green, lasted checked 03/22/2024. 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. All doors and passageways were clear of obstruction and debris at the time of this visit.
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)
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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A MISSION FOR MICHAEL
FACILITY NUMBER: 371881522
VISIT DATE: 04/03/2024
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 CONTINUED
There was a swimming pool on the premises, and it was locked and in accessible to the future residents, the fireplace was covered with a screen, covered with screen and gas supply capped. There was enough clean linen and hygiene items, and there was appropriate lighting in each room. LPA Mixson observed central heating and air conditioning systems, and they are operable.

The Administrator dialed the land line phone number (760) 783-5401, 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 or debris observed currently. The Administrator stated there were no firearms, and/or ammunition on the premises.

The Administrated stated the Facility vehicle was registered, contained a first aid kit and that the facility staff that drive the vehicle are licensed, insured, and training is 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, and type of facility being licensed today (Social Rehabilitation) 772.

CAB 8.0 Pre-licensing / COMP III to be scheduled, at the Riverside Regional Office. 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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