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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850382
Report Date: 05/09/2024
Date Signed: 05/09/2024 11:11:13 AM

Document Has Been Signed on 05/09/2024 11:11 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MISSION LAND LLCFACILITY NUMBER:
405850382
ADMINISTRATOR/
DIRECTOR:		WON, YOUNGFACILITY TYPE:
735
ADDRESS:1522 N STTELEPHONE:
(805) 610-3676
CITY:SAN MIGUELSTATE: CAZIP CODE:
93451
CAPACITY: 4CENSUS: 0DATE:
05/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator - Young OneTIME VISIT/
INSPECTION COMPLETED:
11:56 AM
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 At 9:00am on 05/09/2024, Licensing Program Analyst (LPA) Jeffries arrived at the pre planed appointment time. LPA announced who he is and the reason for the visit.
At 9:10am Licensee/Administrator and LPA conducted a full review and reading of the pre licensing care tools modules. During the review, all applicable questions were affirmed with compliance by observation and documented review. There were no deficiencies discovered during the control tools module read and review.
At 10:05am, Licensee/Administrator, and LPA conducted a physical tour of the facility. LPA observed facility Plan of Operations (PO), Emergency Disaster Plan, Infection control plan and all necessary posting on the facility wall above the desk and computer station. This is a 2 story, 7 bedroom 3 bathroom, with 2 living room and open kitchen areas, the first floor is all client single room occupancy and the upstairs is staff occupancy. There is ample backyard for clients and visitors to be outside with table and built-in pergola for shade. All Client rooms are furnished with proper light, furniture, beds and linins to meet regulation requirements.Clients share the single bathroom. Bathroom had paper towels dispenser and is equipped with liquid soap, non-skid shower mat on tub floor. Water temperature in the facility was measure at 119*(f). LPA observed smoke detector throughout the facility and carbon monoxide detectors in working condition. LPA observed fire clearance (SD850) dated 01/26/2024 for 2 ambulatory, and 2 non-ambulatory clients. LPA observe a working fire extinguisher and a complete first aide kit on hand at the facility. LPA observed emergency food and water supply in the stair storage closet. LPA observed chemicals and hazards to be locked and stored in laundry room. LPA did not find any other violations during the facility tour.
Licensee and LPA conducted a full review of the Component III Orientation, for review as this licensee has three other currently licensed facilities.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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