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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002903
Report Date: 12/04/2023
Date Signed: 12/04/2023 11:57:53 AM

Document Has Been Signed on 12/04/2023 11:57 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH: Program Manager, Bre BertolinoTIME COMPLETED:
12:00 PM
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On 12/04/23, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a required annual inspection. LPA met with Program Manager, Bre Bertolino (S1) and explained purpose of inspection.

LPA and S1 toured the interior and exterior of the facility including the common areas, client bedrooms, bathrooms, kitchen, staff room/office and laundry area. LPA observed the home to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed various required posters throughout as well as other required postings, including House Rules and personal rights. Inside temperature was observed to be 72* degree F. Fire extinguisher last serviced 11/25/23 and ready for emergency use. Facility conducts monthly fire and disaster drills, at different hours of the day. The facility has a large back yard area with seating. There are is a pool at the facility which was found to be secured and locked during visit. LPA observed locked toxins in the laundry area and locked medications in a separate room. LPA observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPA observed paper towels, soap, sanitizer, trash cans and hand-washing posters in the bathroom. Smoke/monoxide alarms were in working order. Games/activities observed on site.

LPA reviewed (1) client file and found the required documentation on file.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 12/31/23.

No deficiencies were observed or cited today. Exit interview conducted.
A copy of this report was printed and given to S1.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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