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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006059
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:57:34 AM

Document Has Been Signed on 12/06/2024 11:57 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 VISTAFACILITY NUMBER:
306006059
ADMINISTRATOR/
DIRECTOR:
APOSTU, DIANAFACILITY TYPE:
772
ADDRESS:160 S. CERRO VISTA WAYTELEPHONE:
(714) 393-3523
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Maggie SumiokaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPAs) Claudia Gutierrez and Nancy Guillen made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Andrea Leyva and the purpose of the inspection was discussed. Compliance Specialist Maggie Sumioka and Residential Supervisor (RS) Amber Wofford were contacted by phone and arrived at 9:30 a.m. and 10:00 a.m. respectively.

During the inspection, LPA Gutierrez and Therapist (TH) Diana Su conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a two-story home with four client bedrooms, six bathrooms, three staff offices, one learning lab room, one dining room, one family room, one kitchen, one laundry room, one recreation room, one hallway storage closet, one medication room and two garages located on the first floor. The second story of the facility is located directly above the recreation room and contains two therapist offices. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area, tennis court, and in-ground swimming pool. Pool was observed to fenced with a self-latching door. Upon arrival, LPA observed two direct care staff and all four clients leaving for a community outing. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 109.7 - 112.2 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be mounted and fully charged with a service tag dated January 4, 2024. Gas stove, microwave, washer, and dryer were all inspected and tested operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication is kept in a cabinet within the medication room, both medication cabinet and medication room were observed to be locked. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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: 12/06/2024
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LPA Guillen reviewed four of four client medications and centrally stored records. LPA Gutierrez reviewed four of four client files and three staff files. One of four client files did not contain an admission agreement, and staff were unable to provide LPA with a copy of client's admission agreement; a Deficiency was cited on today's date. LPA Gutierrez interviewed two staff, and was unable to interview clients as they were not present to be interviewed.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 11:57 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 12/06/2024 at 11:33 AM
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
, 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: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, the licensee did not comply with the section cited above in one of four client files which poses a potential personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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CS stated an admission agreement will be completed and signed by client and a copy provided to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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