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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002903
Report Date: 12/15/2022
Date Signed: 12/15/2022 10:46:06 AM

Document Has Been Signed on 12/15/2022 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:NEWPORT INSTITUTE-FERNWOODFACILITY NUMBER:
095002903
ADMINISTRATOR:MOSER, ASHLEYFACILITY TYPE:
772
ADDRESS:5841 FERNWOODTELEPHONE:
(714) 939-3523
CITY:SHINGLE SPRINGSSTATE: CAZIP CODE:
95682
CAPACITY: 6CENSUS: 0DATE:
12/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Director, Michelle GoodTIME COMPLETED:
11:00 AM
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LPA Lavinia Muscan arrived on 12/15/2022 to conduct a pre-licensing inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Program Director completed the pre-licensing inspection tool domain and the facility was found to be in substantial compliance. LPA and Program Director conducted a walk through of the facility and ensured all physical plant requirements.

There are 4 client rooms upstairs; 2 shared, 2 private, all ambulatory. Additionally there is a dinning room, dinning area, med room, laundry room, kitchen, 2 office rooms and 4 bathrooms. Downstairs there are 4 offices, a classroom, a rec room and one bathroom. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to clients. Fire extinguisher is ready for emergency use. Water temperature read at 116*. A community van was observed outside. Swimming pool has a fence around it.

Component III for ARF was completed with Program Director during today's visit. LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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