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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015650119
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:12:47 PM


Document Has Been Signed on 10/09/2024 04:12 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 RO, 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: 5DATE:
10/09/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Levi Banks, Residential SupervisorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 10/09/24 at 10:13 AM, Licensing Program Analysts (LPAs) Mona Lam and Jonathan Medina conducted an unannounced visit to the licensed facility listed above. The purpose of the visit is to conduct a quarterly non-compliance conference (NCC). LPAs met with Levi Banks, Residential Supervisor. There are five clients on site at this time with three staff members at the beginning of the visit.

Levi informed LPAs that RayJay Peralta left Newport Academy on August 3, 2024. Community Care Licensing did not receive notification within 10 days of a certified administrator taking place after the departure of the former administrator. Based on the non-compliance conference plan, the facility agreed to ensure that the designated administrator at each site is consistent with the administrator on file. The administrator will be working at the facility a minimum of 20 hours a week. This poses an immediate risk to the health, safety, and or personal rights of clients in care. LPA Lam delivered a Type A citation for Title 22 California Code of Regulations 84064(b) Administrator Qualifications and Duties (Refer to LIC 809-D).

LPAs are informed that Kim Claspell-Ochoa is on the pending list for administrator certification since September 4, 2024. In addition, Kim is the potential administrator for Newport Happy Valley.

LPAs observed facility board minutes, staff schedule, LIC 500, and five client files. LPAs observed documented signatures of client rights, house rules, education on reporting abuse, and treatment plans. LPAs reviewed five staff files. Based on five staff files, the training documents are in compliance, except one staff member is missing documentation regarding about health development, sexuality development, and emotional development. Newport Happy Valley is currently working in compliance to document all staff training based on the citation given to Newport Arena on 10/02/2024.

LPAs conducted five (5) client interviews. LPAs conducted a walk through of the facility. LPAs did not observe physical plant deficiencies.
SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Mona LamTELEPHONE: (916) 764-6983
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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 3


Document Has Been Signed on 10/09/2024 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: NEWPORT ACADEMY - HAPPY VALLEY
FACILITY NUMBER: 015650119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2024
Section Cited
CCR
84064(b)

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84064(b) Administrator Qualifications and Duties
Effective January 1, 2000, all group homes shall have a qualified and currently certified administrator.
This requirement is not met as evidenced by:
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Facility will ensure a written plan is delivered to LPA via email by 10/10/24 close of business in getting a certified administrator on site. This plan is a timeline indicating the steps that are going to be taken to ensure the facility will have an administrator before the
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Based on staff interview and discussion, there is no current certified and qualified administrator designated to the facility for two months after the former administrator departure. This poses an immediate risk to the health, safety, and or personal rights of clients in care.
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next non-compliance conference (NCC) quarterly visit.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Mona LamTELEPHONE: (916) 764-6983
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: NEWPORT ACADEMY - HAPPY VALLEY
FACILITY NUMBER: 015650119
VISIT DATE: 10/09/2024
NARRATIVE
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LPAs conducted an exit interview with Levi Banks at 4:10 PM and delivered one (1) deficiency. In addition, LPAs delivered an appeals rights page. Levi Banks's signature confirms the receipt of this document.
SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Mona LamTELEPHONE: (916) 764-6983
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3