198601503-6-16-2025-28-AS-DKOI-DHPR8F-20250616124751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601503
Report Date: 06/16/2025
Date Signed: 06/16/2025 12:48:27 PM

Document Has Been Signed on 06/16/2025 12:48 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	NEWPORT HOUSE		FACILITY NUMBER:	198601503
ADMINISTRATOR/ DIRECTOR:	HARRIS, CYNTHIA		FACILITY TYPE:	735
ADDRESS:	1852 NEWPORT AVE		TELEPHONE:	(626) 797-2935
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 6		CENSUS: 5	DATE:	06/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Maria Carlos, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

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Licensing Program Analyst (LPA) 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.

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 a updated Infection Control Plan dated 06/11/2025.

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. Hallway closet had clean linens and towels. Bathroom has non-skid materials and contains hygiene supplies including liquid soap, paper towel and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area for the clients. Laundry area is located in the kitchen. There are two (2) fire extinguishers last serviced on 11/15/2024.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWPORT HOUSE	FACILITY NUMBER: 198601503
	VISIT DATE: 06/16/2025

NARRATIVE

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Physical Plant/Environment Safety [Cont]: Carbon monoxide was not working when tested. There are no firearms or weapons stored at the facility. Sharps are secure and in a locked cabinet. Cleaning supplies are secure and kept in a locked closet. Hot water temperature were measured between 117.2 deg F to 118.0 deg F which is within the required 105 – 120 degrees.

Operational Requirements: A fire clearance is in place. Surety Bond in place. Fire Drill was conducted on 12/01/2024 and Emergency Preparedness Drill was last conducted on 03/01/2024.

Staffing: A total of eight (8) 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 are in the computer at the facility. LPA reviewed the Administrator and four (4) staff’s files which included personnel record, health screening, TB test results, staff training, and 1st Aid training. However, based on record review, Staff #2 (S2) to Staff #3 (S3’s) files did not have valid 1^st Aid training in file. Administrator, Maria Carlos’s Administrator Certificate expires on 06/18/2026. Based on record review, Administrator’s updated HIV and TB training is in file.

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 five (5) clients are in the Day Program.

Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. 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 all five (5) client files which includes the face sheet, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Functional Capability Assessment, Individual Program Plan (IPP), Appraisal Needs and Services Plan, Centrally Stored Medication Destruction Record, Client Personal Property and Clients Personal Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWPORT HOUSE	FACILITY NUMBER: 198601503
	VISIT DATE: 06/16/2025

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Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for five (5) clients 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 had all required items.

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

Disaster Preparedness: The facility has a complete and updated Emergency Disaster and Mass Casualty Plan dated 06/11/2025.

Emergency Intervention: Not Applicable. Facility does not use restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Maria Carlos.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2025 12:48 PM - It Cannot Be Edited

Created By: Daniel Konishi On 06/16/2025 at 12:23 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: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1503.2

General Provisions

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the carbon monoxide was tested but did not turn on and was not working properly.
	POC Due Date: 06/17/2025
	Plan of Correction
1 2 3 4	Administrator will ensure that the carbon monoxide is working by providing a video of the carbon monoxide being tested and working properly to the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2025 12:48 PM - It Cannot Be Edited

Created By: Daniel Konishi On 06/16/2025 at 12:26 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: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Staff #2 (S2) and Staff #3 (S3's) file did not have a valid first aid training.
	POC Due Date: 06/30/2025
	Plan of Correction
1 2 3 4	Administrator will send Staff #2 (S2) and Staff #3 (S3' valid first aid training card or certificate to the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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