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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:57:08 PM

Document Has Been Signed on 09/06/2022 03:57 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: 5DATE:
09/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Program Director, Priscilla Hernandez, and Residential Supervisor, Marlen Costello-ArRasheedTIME COMPLETED:
02:30 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 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a subsequent Pre-Licensing Inspection visit and met with Staff Member, Shaylia Cooper. Program Director, Priscilla Hernandez, arrived later during visit at 11:20AM and Residential Supervisor, Marlen Costello-ArRasheed, arrived at 12:10PM. LPA conducted first Pre-Licensing visit dated 8/12/2022. Facility type is changing from an Adult Residential Facility to a Social Rehabilitation Facility.

LPA toured the facility and and reviewed additional items. Smoke Alarms and Carbon Monoxide detectors were tested and operational.

LPA, Program Director, and Residential Supervisor discussed the following:
  • Facility submitted Plan to Community Care Licensing (CCL) to have Personnel Files not on site. Files to be electronically stored at their HR headquarters located in the East Bay. Facility plan has been submitted to be reviewed by Policy. If not sufficient, Facility understands that current plan will need to be revised in order to meet regulation.
  • Component III Orientation. LPA reviewed and discussed items in the Component III Orientation with Program Director and Residential Supervisor during visit.
  • LPA observed a hole in the wall located on the stairway leading to the bottom floor (pictures taken); Hole was approximately 8.5x11 inches. Per conversation with Residential Supervisor, ticket was submitted for repairs process to begin. Repairs to begin Wednesday, 9/7/2022. Facility to submit ticket and proof of fixed wall to CCL once completed.

Pre-Licensing completed. Component III Orientation conducted and completed. Facility will be ready to be Licensed as a Social Rehabilitation Facility once Proof of Repairs has been submitted to CCL.

Continued on LIC-809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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: 09/06/2022
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
26
27
28
29
30
31
32
Continued from LIC-809

LPA will submit Pre-Licensing application report to Application Unit Analyst in Sacramento once proof of repairs have been received; Application Unit Analyst will notify Applicant of application status.

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: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2