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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 08/12/2022
Date Signed: 08/12/2022 02:16:44 PM

Document Has Been Signed on 08/12/2022 02:16 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:
08/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Residential Supervisor, Marlen Costello-ArRasheedTIME COMPLETED:
02:25 PM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Pre-Licensing Inspection visit and met with Residential Supervisor, Marlen Costello-ArRasheed. Program Director, Priscilla Hernandez, was available by phone and arrived later during visit. Facility type is changing from an Adult Residential Facility to a Social Rehabilitation Facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA observed COVID-19 signs posted at the entry way and throughout the facility. Facility had sufficient amount of PPE available. All staff present were observed to be wearing a mask.
LPA conducted a walk-through of the facility and observed the following: Facility has 3 bedrooms and 5 full bathrooms and 2 half bathrooms. Facility has two fireplaces that are inactive and are for decor purposes only. Facility currently has 6 clients in care with 2 clients sharing each bedroom. Facility has a swimming pool that is covered and locked by an electronic pool cover. Per conversation with Resident Supervisor, swimming pool is covered and locked at all times unless in use. If clients wish to use the pool, there is a staff member supervising at all times. The electric pool cover is controlled by a key that is stored and locked in the Care Coordinator's office. Per conversation with Program Director, all Staff have their Water Safety Certificates through the Red Cross Association.

Facility has a sufficient amount of perishable and nonperishable foods per regulation. Facility has an adequate supply of kitchen tools. Per conversation with Residential Supervisor, sharps such as knives are stored and locked in the Care Coordinator's office. Sharps are only given to clients during cooking time and they are supervised at all times. Hot Water Temperatures were checked and found to be within regulation with temperatures between the range of 105 degrees F to 120 degrees F. Medications were observed to be locked and inaccessible to clients in care.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/12/2022
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Continued from LIC-809

There are two laundry areas with one area for Employee Use and the other for Client Use. Toxins and Detergents were observed to be locked and inaccessible to clients in care. Per conversation with Resident Supervisor, when Clients do their laundry, they have to ask staff for the detergent. LPA observed Client rooms to be furnished per regulation. Client bathrooms were supplied with paper towels, liquid hand soap, and hand-washing signs. Facility had an adequate supply of the following products available for clients: extra linens, grooming, hygiene, and paper products.

Facility provided LPA with a copy of their weekend activity agenda. Per conversation with Resident Supervisor, Activity agenda is given to clients every week and is accessible online for family and visitors to view.

Per conversation with Resident Supervisor, Main Doors are not equipped with sensors. Currently there is always a staff member present with Clients to ensure their safety. Facility Program will be implementing a system where Clients will be provided with phones and bracelets that will notify the Care Coordinator if they were to leave the property.

Facility has an Emergency Disaster Plan in place. Fire extinguishers were last serviced January 2022. Combination Smoke and Carbon Monoxide Detectors were tested and operational. Facility has a central fire alarm system that is directly connected to the Fire Department. The last Emergency/Fire Drill was conducted July 2022.

LPA unable to review staff files. Per conversation with Program Director, Personnel files were not physically on-site but were located at the Facility headquarters in East Bay.

Pre-Licensing is incomplete with deficiencies to be resolved by Monday, 8/22/2022. A follow up Pre-licensure will be conducted upon resolution of deficiencies.

Exit interview conducted. Copy of report discussed and provided. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
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