306006059-12-13-2021-22-AS-MRED-C9NQDE-20211213110435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006059
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:04:53 AM

Document Has Been Signed on 12/13/2021 11:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	NEWPORT INSTITUTE - CERRO VISTA		FACILITY NUMBER:	306006059
ADMINISTRATOR:	NONOSHITA, MATTHEW		FACILITY TYPE:	772
ADDRESS:	160 S. CERRO VISTA WAY		TELEPHONE:	(714) 393-3523
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY: 6		CENSUS: 0	DATE:	12/13/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diana "Dee" Apostu		TIME COMPLETED:	11:15 AM

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	Licensing Program Analyst (LPA) Michelle Reed conducted an announced Pre-Licensing visit. Upon arrival, LPA met with Dee Apostu (Administrator appointed by applicant), Program Manager Anne Connor and Compliance Manager Crystal Goodwin. Covid signage as well as precautions were in place. LPA's temperature was taken. The initial application to operate a Social Rehab Facility was submitted to the Central Applications Bureau (CAB) on 8/17/21 for a capacity of 6 ambulatory residents. A tour of the physical plant was conducted and the following was observed: Structure: Facility is a two story building with 9 rooms. 4 of the rooms will be resident rooms. They are located downstairs and will be Bedroom #1, #2, #3 and #4. There are 4 bathrooms for resident use. The other rooms will be used as offices. There is also a swimming pool that meets Title 22 regulation and a tennis court, gym and art room and a group recreation room. Shaded patio seating is available. The garage is for storage and car parking only. Bedrooms Residents: At this time there is no fire clearance for bedridden residents. The applicant will have 24-hr staffing and there is no staff room. Emergency lighting was present throughout the facility. Resident bedrooms accommodate residents' furnishings. Nightstands, lights, closet space and dressers were present with appropriate beds and bedding. Water Temperature: The water temperature was observed to be 106 degrees F which meets regulation guidelines. Medications, First Aid Kit & Manual:First Aid kit and manual were present in the facility. Medication will be stored in a locked medication room.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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 INSTITUTE - CERRO VISTA	FACILITY NUMBER: 306006059
	VISIT DATE: 12/13/2021

NARRATIVE

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Linens and Hygiene Supplies: Adequate supply of bed linens, towels and hygiene supplies were present.

Emergency Phone Numbers, Exit Plan: Readily available for review with a facility sketch and exit plan posted

Postings:
The Let Us Know poster is present in the facility and posted in common area

Food Service and Menu:
There was an adequate supply of food. 7- day non-perishable and 2- day perishable food were present in the facility. There was also emergency food and water.

Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide systems are hardwired and were tested and found operational.

Fire Extinguishers:
12 Fully charged extinguishers were mounted to the walls throughout the structure.

Fire Clearance:
Approved on 9/23/21 by Anaheim Fire Department.

Appliances:
Gas stove with an exhaust system with a light, single oven, refrigerator/freezer, microwave, and dishwasher. The washer and dryer are located in a locked laundry room. Residents will be supervised while doing laundry.

Toxins and Sharps:
Locked and stored inaccessible to residents.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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 INSTITUTE - CERRO VISTA	FACILITY NUMBER: 306006059
	VISIT DATE: 12/13/2021

NARRATIVE

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Resident and Staff Files:
Resident records are kept electronically and staff records are both hard copy and electronic. Records will be available upon request for Licensing to review.

Reading Material, Games, Equipment, & Materials:
The facility has a tennis/basketball court and will have group meetings, art, music, yoga, computers, exercise, reading and music

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance.

The Pre licensing is complete. No corrections are needed.

The license will be effective upon final review by the Central Applications Bureau.

An exit interview was conducted with Compliance Manager Crystal Goodwin and Administrator Dee Apostu and a copy of this report was provided

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC809 (FAS) - (06/04)

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