306006157-4-23-2025-22-AS-AORZ-DGHMDW-20250509093149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006157
Report Date: 04/23/2025
Date Signed: 04/23/2025 04:06:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2023 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20231020141730

FACILITY NAME:	NEWPORT INSTITUTE - PERIWINKLE		FACILITY NUMBER:	306006157
ADMINISTRATOR:	CONNOR, ANNE		FACILITY TYPE:	772
ADDRESS:	12822 PERIWINKLE DRIVE		TELEPHONE:	(714) 393-3523
CITY:	NORTH TUSTIN	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 6	DATE:	04/23/2025
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Brianna Graham		TIME COMPLETED:	04:26 PM

ALLEGATION(S):

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Facility did not complete the clients’ Needs and Services Plans

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred conducted an unannounced complaint inspection to continue an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility did not complete the clients’ Needs and Services Plans. During the investigation, LPA conducted interviews with clients in care and staff. LPA reviewed client records obtained.

The investigation determined as follows: regarding the allegation facility did not complete the clients’ Needs and Services Plans, it was reported needs and services plans were not completed within 24 hours of clients 1, 2, and 3’s admission date. Per witness, needs and services plans were not completed or available within 24 hours of admission date for clients 1, 2, and 3.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 22-AS-20231020141730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT INSTITUTE - PERIWINKLE	FACILITY NUMBER: 306006157
	VISIT DATE: 04/23/2025

NARRATIVE

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LPA interviews with clients revealed that six out of six current clients recall completing assessments within 24 hours of admission date, adhering to the facility policy. LPA interviews with four out of four staff members revealed client assessments are completed within 24 hours from admission date per policy. Per admission agreement, client 1 was admitted on 09/17/2023. Per biopsychosocial assessment for client 1, assessment was completed on 09/18/2023. Per psychiatric evaluation for client 1, medical assessment was completed on 10/25/2023. Per admission agreement for client 2, date of admission was 08/01/2023. Per biopsychosocial assessment for client 2, assessment was completed on 08/04/2023. Per psychiatric evaluation for client 2, medical assessment was completed on 08/04/2023. Per admission agreement for client 3, date of admission was 09/08/2023. Per biopsychosocial assessment for client 3, assessment was completed on 09/11/2023. Per psychiatric evaluation for client 3, medical assessment was completed on 09/08/2023.

Per facility’s program plan, needs and services plans must be initiated and completed prior to admission, or within 72 hours of admission. A medical assessment is incorporated into the needs and services plan requirement. A psychiatric evaluation is part of the medical assessment. During LPA record review, client 2 and 3’s needs and services plans met the requirement of being completed prior to or within 72 hours of admission, adhering to the facility policy. Client 1’s needs and services plan did not meet the requirement of being completed prior to or within 72 hours of admission.

LPA interviews with clients revealed that five out of six current clients recall filling out paperwork including admission agreements the same day they were admitted, adhering to the facility policy. One out of six clients cannot recall if they signed an admissions agreement upon entry. LPA interviews with four out of four staff members revealed that all required paperwork including admission agreements are signed prior to or the day of admission per policy.

Based on interviews conducted, observation, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22,Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Brianna Graham and a copy of the report was left with the facility representative along with appeal rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20231020141730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT INSTITUTE - PERIWINKLE	FACILITY NUMBER: 306006157
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/30/2025 Section Cited CCR 81068.2(b)	1 2 3 4 5 6 7	81068.2(b) Needs and Services Plan For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility implemented a checklist to verify needs and services plans are completed. Facility provided checklist to LPA
	8 9 10 11 12 13 14	Based on LPA record review, Client 1’s needs and services plan did not meet the requirement of being completed prior to or within 72 hours of admission which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

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