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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804061
Report Date: 12/02/2022
Date Signed: 12/02/2022 02:56:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20221122144142
FACILITY NAME:NEWPORT INSTITUTE - BAYVIEWFACILITY NUMBER:
216804061
ADMINISTRATOR:KORELIN, SARAFACILITY TYPE:
772
ADDRESS:285 MARGARITA DRIVETELEPHONE:
(714) 393-3523
CITY:SAN RAFAELSTATE: ZIP CODE:
94901
CAPACITY:6CENSUS: 4DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Program Director, Priscilla HernandezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Food is not being stored, prepared and served in a safe and healthful manner
INVESTIGATION FINDINGS:
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At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and was greeted by Staff Member, Starr Williams. Program Director, Priscilla Hernandez, arrived later during visit at approximately 11:00AM.

During the course of the Investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation that food is not being stored, prepared, and served in a safe and healthful manner. Emails and photographs provided to LPA stated concerns that food being served at facility was observed to have maggots. Based on interviews conducted, all main meals for the facility are prepared at a different location and are picked up by facility staff to be served on-site. On 11/19/2022, staff were made aware that maggots were observed in a vegetable dish after being served to 4 of 4 clients (Client 1 - Client 4). Review of Incident Report dated 11/23/2022 and submitted to Community Care Licensing (CCL) on 12/2/2022, indicated that clients were eating dinner and noticed insects inside the vegetables.
Continued on LIC-9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20221122144142
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NEWPORT INSTITUTE - BAYVIEW
FACILITY NUMBER: 216804061
VISIT DATE: 12/02/2022
NARRATIVE
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Continued from LIC-9099

The allegation that Food is not being stored, prepared and served in a safe and healthful manner is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Plan of Corrections reviewed and developed with Program Director. Copy of report, LIC 9099-D, LIC-811 (Confidential Names), and Appeal Rights discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221122144142
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NEWPORT INSTITUTE - BAYVIEW
FACILITY NUMBER: 216804061
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2022
Section Cited
CCR
81076(a)(1)
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*Amended* 81076 FOOD SERVICE: (a) In a social rehabilitation facility providing meals to clients...(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients...All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Licensee to submit a self-certification that (1)they will draft a written plan of action to ensure food provided to clients is selected, stored,prepared,and served in a safe and healthful way, (2) conduct an Inservice Training for all staff regarding safe food/food handling practices. Self-Certification to be
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This requirement was not met as evidenced by: Based on interviews conducted and review of documents, Licensee did not ensure that food provided to Clients was served in a safe and healthful manner. This poses an immediate health and safety risk to Clients in care.
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submitted to CCL by POC due date of 12/3/2022. Inservice to include the following: Date of Training,Training Topics,Job Role, Staff Names,and Signatures. Inservice Training and Written Plan to be submitted to CCL for review and approval by POC due date of 12/12/2022.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3