<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015650119
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:13:55 PM


Document Has Been Signed on 03/21/2024 02:13 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 BRUNO ASC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:NEWPORT ACADEMY - HAPPY VALLEYFACILITY NUMBER:
015650119
ADMINISTRATOR:RAYJAY PERALTAFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 6DATE:
03/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Sara KoerlinTIME COMPLETED:
02:20 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
On 3/21/2024 at 12:40pm, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct a case management visit following the Non-Compliance Conference conducted on 12/7/2023. LPA met with Sara Koerlin, Residential Supervisor.

LPA conducted a walk through of the facility. LPA did not observe physical plant deficiencies. LPA observed that the facility had moved kitchen operations to the outside area that used to be utilized as a school building. LPA observed that the evacuation plans and facility sketches on site were up to date with this change.

LPA requested the staff schedule, the facility board minutes, and the client files. LPA received the board minutes via email. LPA reviewed the staff schedule and saw that the Administrator was not included on the staff schedule. LPA requested that the facility send the times that the Administrator's has been on site for the week of 3/18/2024 to 3/24/2024 by end of day on 3/27/2024.

LPA reviewed the treatment plans, admission agreements, and acknowledged house rules for six clients. LPA found that the six clients had these plans in their digital files including client and authorized representative signatures.

LPA conducted three confidential interviews.

No deficiencies were cited during this visit. LPA conducted an exit interview with Sara Koerlin, Residential Supervisor at 2:12pm whose signature confirms the receipt of this document.

SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 908-0374
LICENSING EVALUATOR NAME: Selena HoodTELEPHONE: 408-324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 1