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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201164
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:47:44 PM

Document Has Been Signed on 08/17/2023 02:47 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: 5DATE:
08/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sara Koerlin, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/17/2023 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Care Coordinator, Aurora Ortiz and explained the purpose of the visit. Administrator, Sara Koerlin arrived an hour later. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Combination smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 6/27/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 120 degrees F in the client's bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction. Last fire drill was conducted on 7/21/2023.

LPA reviewed 5 client and 4 staff files starting at 10:10AM. LPA interviewed 2 staff and 2 clients starting at 1:05PM. LPA reviewed a sample of client's medications starting at 2:00PM.

At 11:30AM, LPA was informed that S3's file is incomplete and unable to review S3's records.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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Document Has Been Signed on 08/17/2023 02:47 PM - It Cannot Be Edited


Created By: Grace Luk On 08/17/2023 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEWPORT INSTITUTE - KILKARE
FACILITY NUMBER: 019201164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(a)
(e) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having S3's file completed which poses a potential health and safety risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator has agreed to obtain S3's file and submit a copy to CCLD by POC date. In addition, facility will audit their staff files and make sure all staff have updated files for future reviews.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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