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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:11:18 PM

Document Has Been Signed on 09/24/2024 01:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NEWPORT INSTITUTE - BAYVIEWFACILITY NUMBER:
216804061
ADMINISTRATOR/
DIRECTOR:		MAXWELL KELLERFACILITY TYPE:
772
ADDRESS:285 MARGARITA DRIVETELEPHONE:
(714) 393-3523
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Staff Members, Stephanie Neher and Kimeeco Epps, and Program Manager, Hope HurstTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Stephanie Neher. Program Manager, Hope Hurst, arrived during visit at approximately 10:15AM. Facility is a Long Term Social Rehabilitation Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed there were 6 clients in care and 7 staff members on site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster found that Staff Members 1 and 2 (S1 and S2) were not fingerprint cleared or associated to the facility as required. LPA also observed that Staff Member 3 (S3) was not associated to the facility as required. LPA notified S1 and S2 to leave the premises and saw that S3 was associated to the facility during visit (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)). At approximately 11:45AM, LPA conducted a walk-though of the facility with Staff Member, Kimeeco Epps. LPA observed the following: Facility was at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Toxins were observed to be stored inaccessible to clients. A sample size of 5 sinks were tested for hot water temperature. 4 of 5 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit (see technical advisory, LIC9102, regulation 81088(e)(1)) and 1 of 5 sinks was found to be at 104.9F. Facility's fire extinguishers and sprinkler system were last inspected January 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

During walkthrough, LPA observed that the facility had converted a staff office and a double occupancy room into two single occupancy rooms. The facility previously had 3 shared client bedrooms for a total capacity of 6 clients. Facility now has two single client bedrooms, and two shared client bedrooms. Licensee to submit an updated facility sketch to indicate the changes made by 10/04/2024.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NEWPORT INSTITUTE - BAYVIEW
FACILITY NUMBER: 216804061
VISIT DATE: 09/24/2024
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Document Link IconContinued from LIC809C

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

***An immediate civil penalty assessment in the total amount of $300.00 has been issued for a lack of criminal
record clearance and/or associations as required for S1, S2, and S3 (See LIC 421BG).

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC811 (Confidential Names) Plan of Corrections, and Appeal Rights discussed and provided to Staff Member. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/24/2024 01:11 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 09/24/2024 at 12:36 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NEWPORT INSTITUTE - BAYVIEW
FACILITY NUMBER: 216804061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not ensure that Staff members 1, 2, and 3, (S1, S2, and S3) had the proper background clearance and/or associations required to provide care at the facility. This poses an immediate health and safety risk to clients in care.
POC Due Date: 09/25/2024
Plan of Correction
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Licensee to ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for an employee prior to them working. Plan to be submitted by POC due date of 09/25/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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