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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002903
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:17:08 AM

Document Has Been Signed on 10/28/2024 11:17 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/
DIRECTOR:		MOSER, ASHLEYFACILITY TYPE:
772
ADDRESS:5841 FERNWOODTELEPHONE:
(714) 939-3523
CITY:SHINGLE SPRINGSSTATE: CAZIP CODE:
95682
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Residential Supervisor Sara KoerlinTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/28/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived unannounced to conduct a required annual inspection. LPA met with Residential Supervisor Sara Koerlin and explained purpose of inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (3) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills.


LPA and staff toured the interior and exterior of the facility including the common areas, client bedrooms, bathrooms, kitchen, staff room/office and laundry area. Fire extinguisher ready for emergency use. Disaster drills current. 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. Smoke/monoxide alarms were in working order. Games/activities observed on site.


LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department.

No deficiencies were observed or cited today. Exit interview conducted.

A copy of this report was printed and given to Residential Supervisor Sara Koerlin.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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