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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:35:32 PM

Document Has Been Signed on 10/09/2024 03:35 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:
10/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Residential Supervisor, Reyna ColemanTIME VISIT/
INSPECTION COMPLETED:
03:45 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
At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Residential Supervisor, Reyna Coleman. 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 9:30AM, LPA reviewed the Facility's Staff Roster found that Staff Members 1, 2, and 3 (S1, S2, and S3) were not associated to the facility as required. LPA observed that all three staff members were associated to the facility during visit (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)). LPA spoke with Licensing and Compliance Manager who stated that they will be conducting an audit of the region to ensure they maintain compliance with Licensing regulations.

LPA reviewed staff and client files, and client medication. Staff files were all found to be well organized, thorough and contained the required documentation. Staff files were all found to have current First Aid and CPR certification. During Client File review, LPA observed the following: 3 of 6 clients did not have signed Personal Rights or Consent Forms and 2 of 6 clients did not have admissions agreements on file (deficiency cited and technical violation issued, see LIC809D and LIC9102, regulations 81072(a) and 81068(a)). Medication was centrally stored and secure. LPA and Residential Supervisor discussed unusual incident reports and when they are to be submitted to Licensing for review.

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 $250.00 has been issued for a repeat violation of H&S Code 1522(c)(1) within a 12 month period. (See LIC421IM).***

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Violation/Advisories), LIC421IM (Civil Penalty), Plan of Corrections, and Appeal Rights discussed and provided to Residential Supervisor. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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
Document Has Been Signed on 10/09/2024 03:35 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/09/2024 at 02:51 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: 10/09/2024

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
1
2
3
4
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 associations required to provide care at the facility. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/10/2024
Plan of Correction
1
2
3
4
Licensee to submit a self-certification stating how they will ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility prior to working per Title 22 regulations. Plan to include addressing background audits, staff training, and policy and procedure review. Self Certification to be submitted by POC due date of 10/10/2024. Plan to be submitted by POC due date of 10/20/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/09/2024 03:35 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/09/2024 at 02:51 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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81072(a)
Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observations made, Licensee did not ensure that 3 of 6 clients had their personal rights/consent forms signed as required. This poses a potential health and safety risk to clients in care
POC Due Date: 10/20/2024
Plan of Correction
1
2
3
4
Licensee to submit proof that identified clients have signed personal rights and consent forms. Licensee to conduct an in-service training reviewing the intake admissions process to ensure that the forms are being completed timely. In-service to include the following: Topic, Date, Length of Training, Job Role, Staff Names and Staff Signatures. Training to be submitted to CCL by POC Due Date of 10/20/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4