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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:37:03 PM

Document Has Been Signed on 11/17/2022 02:37 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: 3DATE:
11/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Priscilla Hernandez, Program Manager via PhoneTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Newport Healthcare - Bayview for the purpose of following up on an incident report that was forwarded to the Regional Office (RO) on October 31, 2022. LPA was greeted at the door by a Staff Member and was granted access into the facility.

During the Case Management-Incident Inspection, LPA requested the following documents:

-Staff Roster
-Resident Roster
-LIC 602 and Care Plan for R1
-Facility Menu

No deficiencies were observed or cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Staff Member.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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