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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006059
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:51:40 PM

Document Has Been Signed on 12/28/2023 12:51 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
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:
12/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Alexis Le - Residential SupervisorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr arrived at the facility for the purpose of conducting a Case Management inspection to follow up on the visit from 12/21/2023. LPA was greeted and granted entry by staff and brought to Residential Supervisor (RS) Alexis Le's office.

LPA stated that amendments were made to the forms RS signed at the previous visit and required new signatures. LPA also requested proof of training completed by the staff who made the medication error (S1) on 11/15/2023. RS printed out emails between S1 and their trainer (T1).

Based on documentation, LPA determined the previously issued deficiency has been corrected. An exit interview was conducted, new signatures were obtained and a copy of this report was provided.
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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