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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601503
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:17:01 PM

Document Has Been Signed on 05/21/2024 12:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NEWPORT HOUSEFACILITY NUMBER:
198601503
ADMINISTRATOR/
DIRECTOR:		HARRIS, CYNTHIAFACILITY TYPE:
735
ADDRESS:1852 NEWPORT AVETELEPHONE:
(626) 797-2935
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Maria Carlos - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPA)s Bennette Pena and Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs were met by Maria Carlos, Administrator and explained the purpose of the visit. The facility is approved to serve for (6) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. The facility is level 3. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (3) client bedrooms, (2) bathrooms, a living room, activity/office room, kitchen, dining area, backyard and detached garage. Currently, there are six (6) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fire place in the living room that is not secured and fully covered. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has outdoor furniture but the patio umbrella is broken. Laundry area is located in the kitchen. There are two (2) fire extinguishers last serviced on 12/04/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. Readings were 114.8 deg F in bathroom #1 and 111 deg F in bathroom #2.

Operational Requirements: The Infection Control Plan has been developed and submitted to CCL. A fire clearance is in place. Surety Bond in the amount of $15000 is in effect and expires on 12/01/2024. Fire and Emergency Preparedness Drill is being conducted on a monthly basis and last drill was conducted on 03/01/2024. *****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWPORT HOUSE
FACILITY NUMBER: 198601503
VISIT DATE: 05/21/2024
NARRATIVE
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Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Staff files and other facility files are not maintained and kept in the facility. Administrator had to get the files from another facility. LPAs reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 6/18/2024.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that none of the clients have their own personal cell phone or IPad. LPA was not able to conduct interviews with the clients as all (6) clients are in the Day Program.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C6 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are bubbled packed. First aid supplies in the facility was incomplete and expired on 05/31/2020.

Incidental Medical Services: None of the clients at this home has a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited, exit interview, appeals rights and a copy of this report was provided to the Administrator, Maria Carlos.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/21/2024 12:17 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/21/2024 at 11:49 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWPORT HOUSE
FACILITY NUMBER: 198601503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that Staff files and other facility files are not maintained and kept in the facility. Administrator had to get the files from another facility which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will ensure that facility files are kept and maintained in the facility. Administrator will send a written statement that she had read, reviewed and understood Title 22 Regs. 80066(a) to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, ecord review, the Administrator did not comply with the section cited above in that First aid supplies in the facility was incomplete and expired on 05/31/2020 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will submit photos and receipts of the new/updated first aid supplies kit to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/21/2024 12:17 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/21/2024 at 12:01 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWPORT HOUSE
FACILITY NUMBER: 198601503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that knives were stored in an unlocked upper kitchen cabinet which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 05/22/2024
Plan of Correction
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Administrator stored the knives in a locked kitchen cabinet during the visit. **Deficiency cleared during the visit.**
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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