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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601503
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:49:05 PM

Document Has Been Signed on 10/28/2021 03:49 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
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:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator / Maria CarlosTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Administrator / Maria Carlos who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years old, Ambulatory only. During today's visit, LPA toured the physical plant (inside/outside) and checked the food supplies.

The facility is located in a residential area. A tour of the single-story facility includes: three (3) client bedrooms, two (2) bathrooms, activity/storage room, living room, kitchen, dining area, indoor/outdoor activity areas, and a detached 2 car garage. All medications for residents who need assistance are kept locked and inaccessible to other clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers (2) were fully charged and in compliance. The front yard is well landscaped with steps that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The detached 2 car garage is kept locked and inaccessible to clients at all times.

The following concerns were observed during today's visit;
  • At 2:17PM, the hot water temperature was tested in the kitchen and measured at 128.3 degrees F. At 2:47PM, the hot water temperature was tested in bathroom #2 and measured at 125.6 degrees F. At
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWPORT HOUSE
FACILITY NUMBER: 198601503
VISIT DATE: 10/28/2021
NARRATIVE
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2:55PM, the hot water temperature was tested in bathroom #1 and measured at 124.7 degrees F.
  • At 2:21PM, LPA observed bleach and detergent underneath the kitchen sink, left unlocked and accessible to clients.
  • At 2:24PM, LPA found scissors (2) in the kitchen cabinet drawer left unlocked and accessible to clients.

Due to time constraints LPA had to terminate visit and will return on a later date to conclude the Required - 1 Year Inspection by focusing on the infection control domain and reviewing client medications.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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Document Has Been Signed on 10/28/2021 03:49 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 10/28/2021 at 03:26 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: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited
CCR
80088(e)(1)

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Buildings and Grounds. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by;
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Administrator will ensure that the hot water
temperature is maintained between 105
degrees F - 120 degrees F throughout the
facility as required and submit a log for the next 24 hours showing the actual reading in the kitchen and bathrooms #1 and #2.
POC must be submitted to CCL by the POC
due date.
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At 2:17PM, the hot water temperature was tested in the kitchen and measured at 128.3 degrees F. At 2:47PM, the hot water temperature was tested in bathroom #2 and measured at 125.6 degrees F. At 2:55PM, the hot water temperature was tested in bathroom #1 and measured at 124.7 degrees F. This poses an immediate health, safety risk to persons in care.
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Type A
10/28/2021
Section Cited
CCR80087(g)

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Buildings and Grounds. 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.

This requirement is not met as evidenced by;
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The Administrator confiscated the bleach, detergent and scissors and locked them in the cabinet making them inaccessible to clients.

*Citation was cleared at the visit and no further action is needed*

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At 2:21PM, LPA observed bleach and detergent underneath the kitchen sink, left unlocked and accessible to clients. At 2:24PM, LPA found scissors (2) in the kitchen cabinet drawer left unlocked and accessible to clients. This poses an immediate health, safety risk to persons in care.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


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