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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006059
Report Date: 12/21/2023
Date Signed: 01/04/2024 10:45:18 AM

Document Has Been Signed on 01/04/2024 10:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NEWPORT INSTITUTE - CERRO VISTAFACILITY NUMBER:
306006059
ADMINISTRATOR:APOSTU, DIANAFACILITY TYPE:
772
ADDRESS:160 S. CERRO VISTA WAYTELEPHONE:
(714) 393-3523
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Alexis Le - Residential SupervisorTIME COMPLETED:
01:10 PM
NARRATIVE
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This is an Amended report.

On this day, Licensing Program Analyst (LPA), Dwayne Mason Jr made an unannounced inspection to the facility for the purpose of following up on a Special Incident Report submitted by the facility to the Orange County Regional Office on November 15, 2023, regarding an incident involving a medication error. LPA was greeted and granted entry by facility Residential Supervisor (RS) Alexis Le after introducing self and stating the reason for the inspection.

Two staff members were interviewed on this day and LPA conducted a file review on Client 1 (C1). It was determined that Client 1 (C1) was given a higher dose of medication than prescribed. Based on staff interviews, LPA determined that on the day of the medication error, client vitals were taken, no changes were noted. Facility notified psychiatrist and followed psychiatrist’s recommendation. The staff who made the error received a final written warning and cannot go into the medication room until completing re-training on medication management. Client 1 (C1) was not interviewed because they no longer reside in the facility.

LPA was accompanied by Residential Supervisor (RS) and conducted a tour of the facility’s physical plant and made a Health & Safety inspection reviewing the facility’s routes of ingress and egress. No health and/or safety concerns were evidenced during the inspection.

Based on interviews conducted with staff, LPA determined that Client 1 (C1) was given a higher dose than prescribed on 11/15/2023. There were no adverse effects. RS stated that all staff would be re-trained. See deficiency page for deficiencies cited. Exit interview conducted and report was reviewed with Residential Supervisor, Alexis Le.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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Document Has Been Signed on 01/04/2024 10:41 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/26/2023 11:48 AM


Created By: Dwayne L Mason On 12/21/2023 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT INSTITUTE - CERRO VISTA
FACILITY NUMBER: 306006059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
HSC
80075(5)(B)

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Health Related Services.
Once ordered by the physician the medication is given according to the physician's directions.
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RS stated Staff 2 received a final written warning and cannot go in med room until re-training on 12/27/2023. RS will submit via email a signed copy of Staff 2's completed training by POC due date of 12/28/2023.
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Based on staff interviews conducted, the facility did not comply with the section sited above on 11/15/2023 as it was determined that a client was given more than the prescribed dose of medication. This poses a potential health and safety risk.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT INSTITUTE - CERRO VISTA
FACILITY NUMBER: 306006059
VISIT DATE: 12/21/2023
NARRATIVE
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This is an Amended report.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3