306004471-10-17-2022-22-AS-JCHO-CKAR6V-20221017124522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004471
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:45:36 PM

Document Has Been Signed on 10/17/2022 12:45 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	NEWPORT HEIGHTS MANOR		FACILITY NUMBER:	306004471
ADMINISTRATOR:	RAMIL DE LOS SANTOS		FACILITY TYPE:	740
ADDRESS:	466 E. 16TH STREET		TELEPHONE:	(949) 612-9820
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	6	CENSUS: 6	DATE:	10/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Merlita Palo		TIME COMPLETED:	01:00 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	On 10/17/2022 at 10:10am, Licensing Program Analyst (LPA) Jessica Cho arrived at Newport Heights Manor to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 10:12am, LPA Cho was greeted and granted entry by Caregiver Joseph Manlutac and completed the Coronavirus 2019 (COVID-19) screening procedure. Caregivers Merlita Palo and Maria Janet Manlutac were also present during today's visit. At 10:19am, LPA spoke with Administrator (Admin) Cristina Valerio via a telephone call and discussed the following: Staff #1 (S1) was not associated. LPA verified S1 was fingerprint cleared via the DOJ Applicant Fingerprint Response. LPA reminded that the annual licensing fee is due which was paid during the visit. In addition, Admin authorized Caregiver Merlita Palo to assist with the tour and sign the report on the Admin's behalf. As of today, there are no active COVID-19 cases. Facility screens and documents temperatures of visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) measured at 11.5"x18" which did not meet the size requirement. The Administrator's Certificate for Cybele Magtibay expired on 07/03/2022 and 09/27/2022 for Ramil Delos Santos. Per Administrator Valerio, the coursework have been completed. The facility is licensed for six non-ambulatory residents and has a hospice waiver for three. There are currently six residents living in the facility of which one is in hospice care. At 10:30am, LPA Cho conducted a tour of the physical plant with Caregiver Merlita Palo. The two story home consists of five resident bedrooms and three resident bathrooms. There are three private bedrooms on the second floor. The facility also has a living room, sun room converted into a family room, kitchen, laundry room, and an attached two-car garage utilized as an office/storage space. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT HEIGHTS MANOR	FACILITY NUMBER: 306004471
	VISIT DATE: 10/17/2022

NARRATIVE

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LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured between the ranges of 117.6 degrees Fahrenheit in Bathroom #1, 113.1 to 127.2 degrees Fahrenheit in Bathroom #2, and 124.3 to 127.9 degrees Fahrenheit in Bathroom #3. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 10/14/2021. As of today, the facility did not meet the fire extinguisher service date. Per Admin, the fire extinguisher is scheduled to be serviced on October 20, 2022. In addition, two carbon monoxide and three of ten smoke detectors were not in operating condition. All auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No bodies of water was present, and there was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gates were self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs.

At 10:58am, LPA spoke with Administrator Cristina Valerio and consulted the following: to ensure S1 is associated immediately and to update facility staff on Guardian, to enlarge and post the PUB475 in the size requirement by the entry way, to ensure the hot water is within range, to immediately service the fire extinguisher, and to also immediately repair the three smoke detectors and two carbon monoxide detectors.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Caregiver Merlita Palo and Administrator Cristina Valerio via a telephone call, and a copy of this report (along with LIC809, LIC809C, LIC809D, 811, appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 10/17/2022 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT HEIGHTS MANOR	FACILITY NUMBER: 306004471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, the facility did not ensure one of three staff were not associated to the facility prior to employment as required which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 10/24/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator acknowledges and agrees to associate S1 and to forward proof of correction by POC due date to LPA Cho.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC809 (FAS) - (06/04)

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