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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201164
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:46:14 PM

Document Has Been Signed on 06/02/2022 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:NEWPORT INSTITUTE - KILKAREFACILITY NUMBER:
019201164
ADMINISTRATOR:KORELIN, SARAFACILITY TYPE:
772
ADDRESS:227 KILKARE ROADTELEPHONE:
(714) 393-3523
CITY:SUNOLSTATE: CAZIP CODE:
94586
CAPACITY: 6CENSUS: 6DATE:
06/02/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Crystal Goodwin, Applicant Representative; Sara Korelin, AdministratorTIME COMPLETED:
11:45 AM
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Facility Type: SRF
Application Type: CHOFT
Capacity: 6
Census (if any clients in care): 6

Method: Telephone call with CAB
COMP II Participants: Crystal Goodwin, Applicant Representative; Sara Korelin, Administrator
Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Victoria Christiansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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