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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006157
Report Date: 10/28/2024
Date Signed: 10/28/2024 09:17:32 AM

Document Has Been Signed on 10/28/2024 09:17 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 - PERIWINKLEFACILITY NUMBER:
306006157
ADMINISTRATOR/
DIRECTOR:		BRIANNA GRAHAMFACILITY TYPE:
772
ADDRESS:12822 PERIWINKLE DRIVETELEPHONE:
(714) 393-3523
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Parastou PakereshtTIME VISIT/
INSPECTION COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in-conjunction with complaint visit 22-AS-20241022091842. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the visit, LPA requested records for Clients #1-3. Facility staff is unable to access records.












Based on observations made during today's visit, deficiency is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Exit interview conducted and a copy of this report as well as appeal rights were provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 09:17 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/28/2024 at 08:51 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 - PERIWINKLE
FACILITY NUMBER: 306006157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
81070(d)

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All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying...This req is not met as evidenced by:
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Licensee to provide the following records to Licensing by POC due date: Medical assessments, progress notes, needs and appraisals and any/ all written assessments pertaining to clients 1-3.
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Based on observation, Licensee failed to ensure client records were available for licensing to inspect. Staff is unable to access electronic records. This poses a potential health and safety risk to clients in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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