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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201164
Report Date: 07/22/2022
Date Signed: 07/22/2022 06:44:49 PM

Document Has Been Signed on 07/22/2022 06:44 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 4DATE:
07/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alexander Vandenbelt, Program Director
Linda Feiler, Care Coordinator		TIME COMPLETED:
04:15 PM
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On 7/22/2022 at 12:45AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Program Director, Alexander Vandenbelt.

The facility's fire clearance was approved for 6 ambulatory clients.



LPA toured facility including but not limited to client's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. LPA observed lighting in all rooms. LPA observed facility had a 7-day of nonperishable and 2-day of perishable food supplies. Facility had combination smoke and carbon monoxide detectors and observed in operating conditions. First aid kit was complete. Medications were locked in the medication room.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. Each client did not have a night stand and a chair in the room.

2. Hot water was measured at 125 degrees F.

3. Outdoor pathways were uneven in the backyard. Bricks were uneven and some trims on the pathways were lifting.

4. Three clients did not have TB test and two clients did not have medical assessment on file. Medical assessment were signed by nurse practitioner instead of a doctor.

5. Personnel records were not maintained on site. Facility does not have a waiver to keep personnel records off site.

(Continue on LIC9099C...)

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEWPORT INSTITUTE - KILKARE
FACILITY NUMBER: 019201164
VISIT DATE: 07/22/2022
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6. Facility had dim emergency light/flash light that was flickering.

7. Facility did not have night light in bathrooms.

8. Facility's emergency disaster plan only had one shelter relocation.

Facility will submit proof of corrections to CCLD on/before 8/12/2022.

Exit interview conducted with Linda Feiler. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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