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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601503
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:51:50 PM

Document Has Been Signed on 11/05/2021 12:51 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:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator / Maria CarlosTIME COMPLETED:
01:15 PM
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) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During the Required - 1 Year inspection conducted on 11/5/21, LPA arrived at the facility at 8:25AM and observed Staff #1 (S1) outside by the street talking to an individual in a car for 10 minutes. At 8:35AM, LPA walked inside the facility with S1 and observed 6 clients were left inside the facility alone without staff supervision. S1 was the only staff person on duty at the time. This poses an immediate health, safety risk to the clients in care.

The following deficiency was 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: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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
Document Has Been Signed on 11/05/2021 12:51 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 11/05/2021 at 11:27 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
80078(a)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
LPA arrived at the facility at 8:25AM and observed Staff #1 (S1) outside by the street
1
2
3
4
5
6
7
Administrator will schedule an in-service training on the importance of not leaving clients unattended, without staff supervision and employed in numbers necessary to meet the clients needs. A copy of the materials discussed during the training and signatures of all staff present must be forwarded to the CCL office by the POC due date.
8
9
10
11
12
13
14
talking to an individual in a car for 10 minutes. At 8:35AM, LPA walked inside the facility with S1 and observed 6 clients were left inside the facility alone without staff supervision. S1 was the only staff person on duty at the time. This poses an immediate health, safety risk to the clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


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