374604377-4-25-2024-08-AS-CLOZ-D4NSC6-20240425134502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604377
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:46:48 PM

Document Has Been Signed on 04/25/2024 01:46 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	A MISSION FOR MICHAEL		FACILITY NUMBER:	374604377
ADMINISTRATOR/ DIRECTOR:	ROMANELLI, KEAN AMFT		FACILITY TYPE:	772
ADDRESS:	6477 GOLDENBUSH DRIVE		TELEPHONE:	(949) 371-3857
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92011
CAPACITY: 6		CENSUS: 5	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Kristy Concepcion, Clinical Director, and Eric Schlothan Clinical Director		TIME VISIT/ INSPECTION COMPLETED:	01:55 PM

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) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Sara Ruiz client coordinator. LPA discussed the purpose of the visit with client coordinator Ruiz. Clinical Director’s Kristy Concepcion and Eric Schlothan later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) clients all of whom may be ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is five (5) clients living at the facility. There were 5 clients present at the facility site during the inspection who later left for an outing. LPA, accompanied by client coordinator Ruiz and Hindy Hertz, Residential Supervisor, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 72 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water at 111 degrees F; sink in restroom #1 delivered hot water at 109.8 degrees F; sink in restroom #2 delivered hot water at 109.9 degrees F; sink in restroom #3 delivered hot water at 115.9 degrees F, and sink in restroom #4 delivered hot water at 105.1 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking and dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to clients. Medications were properly labeled, as required, and stored in the locked medication room. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: A MISSION FOR MICHAEL	FACILITY NUMBER: 374604377
	VISIT DATE: 04/25/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per client coordinator Ruiz, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present (04) and serviced within the last 12 months. First aid kits were complete and readily accessible. Fire drills were completed on a quarterly basis.

LPA was unable to interviewed staff and clients as they left for an outing during the inspection. LPA reviewed staff and client records. LPA tour and records review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a confidential location. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Clinical Director’s Kristy Concepcion and Eric Schlothan to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Clinical Director’s Kristy Concepcion and Eric Schlothan to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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