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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:28:37 PM

Document Has Been Signed on 05/12/2023 12:28 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NEWPORT INSTITUTE - BAYVIEWFACILITY NUMBER:
216804061
ADMINISTRATOR:KORELIN, SARAFACILITY TYPE:
772
ADDRESS:285 MARGARITA DRIVETELEPHONE:
(714) 393-3523
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 6DATE:
05/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Residential Supervisor, DiegoTIME COMPLETED:
12:40 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Residential Supervisor, Diego Chavez. Program Director, Michelle Barnett, arrived later during visit at approximately 10:00AM. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 03/30/2023. Report states that on 03/28/2023, Client 1 (C1) was observed to not be in their room during a routine check. Facility searched the area, notified Local Law Enforcement and located C1. Local Law Enforcement determined that C1 would be taken to the hospital to be evaluated. C1 returned to the facility the next day on 03/29/2023. Facility made all appropriate notifications per regulation.

LPA discussed C1 with Program Director and Associate Clinical Director. LPA requested and reviewed documents. As of today, 05/12/2023, C1 has been discharged from the facility due to completing their treatment plan.

LPA conducted a walk-through of the facility.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) 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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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