<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601503
Report Date: 06/09/2022
Date Signed: 06/09/2022 10:15:03 AM

Document Has Been Signed on 06/09/2022 10:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NEWPORT HOUSEFACILITY NUMBER:
198601503
ADMINISTRATOR:HARRIS, CYNTHIAFACILITY TYPE:
735
ADDRESS:1852 NEWPORT AVETELEPHONE:
(626) 797-2935
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Monique Jordan, co-administratorTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with co-administrator Monique Jordan and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by Lanterman Regional Center as a Level 3 facility.

All client bedrooms were toured. Each bedroom has 2 beds (shared rooms), linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 107.3 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in the kitchen cabinets or laundry room cabinets. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside or outside the facility. LPA was screened at the time of entry, however facility does not have a screening station in the entrance with PPE's and sanitizer. Staff document client temperatures and symptoms daily as required.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2