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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804061
Report Date: 12/20/2022
Date Signed: 12/20/2022 12:53:07 PM

Document Has Been Signed on 12/20/2022 12:53 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:
12/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Residential Supervisor Georgiamae Wallace and Program Director, Priscilla HernanadezTIME COMPLETED:
10:45 AM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit, and met with Staff Member, Ashley Dillard. Residential Supervisor Georgiamae Wallace arrived during visit at approximately 10:15AM, and Program Director, Priscilla Hernandez, arrived during visit at approximately 11:00AM. The purpose of the visit is to follow up on a self-reported incident submitted to Community Care Licensing (CCL), and to obtain signatures for an amended document.

LPA, Residential Supervisor, and Program Director discussed the following:
  • Incident report received by CCL on 12/12/2022. Incident report states that on 12/04/2022, Client 1 (C1) reported to facility staff that they were having difficulty breathing, and requested for their inhaler. Staff were unable to locate device and contacted Emergency Personnel. Emergency Personnel conducted their assessment and determined that C1 did not need further assistance. C1 was advised to get rest.
Per conversation with Residential Supervisor and Program Director, C1 is doing fine and has had no further incidents.
  • Amended document and signature for facility visit conducted on 12/02/2022
  • Staff Training
  • Staff Background Clearances

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, LIC 811 (Confidential Names), and amended document discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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