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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006157
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:26:51 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
10/22/2024 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20241022091842
FACILITY NAME:NEWPORT INSTITUTE - PERIWINKLEFACILITY NUMBER:
306006157
ADMINISTRATOR:BRIANNA GRAHAMFACILITY TYPE:
772
ADDRESS:12822 PERIWINKLE DRIVETELEPHONE:
(714) 393-3523
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 5DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Brianna GrahamTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility did not complete admission agreement
Facility did not complete client's needs and services plan timely
Facility is not documenting the client's progress in meeting goals
Facility is not following plan of operation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to continue an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility did not complete admission agreement, facility did not complete client’s needs and services plan timely, facility is not documenting the client’s progress in meeting goals, and facility is not following plan of operation. During the investigation, LPA conducted interviews with clients in care. LPA reviewed records obtained.

The investigation determined as follows: regarding the allegation facility did not complete admission agreement, it was reported initial admission assessment was not completed on admission for client 2 (C2).

Continued on LIC9099-C dated 5/30/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 7
Control Number 22-AS-20241022091842
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: 05/30/2025
NARRATIVE
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LPA record review revealed admission date for C2 was 09/18/2024 per face sheet and admission agreement. The biopsychosocial assessment for C2 was signed by clinical staff on 09/24/2024, six days after admission. Per facility program plan, admission assessments must be completed prior to admission, or within 72 hours of admission. LPA interviews with two out of two clients present at the facility stated they recall being assessed by the clinical team.

Regarding the allegation facility did not complete client’s needs and services plan timely, it was reported the biopsychosocial assessment did not include documented evidence of functional capabilities for client 1 (C1), C2, and client 3 (C3).

LPA record review for C1, C2, and C3 revealed the biopsychosocial assessments do not include functional capabilities assessments. In reviewing the program plan for the facility, the plan states “Prior to accepting a client into treatment at Newport Institute, an assessment of a client’s functional capabilities will be completed. This will be used to develop the Needs and Services Plan. The LIC 9172 will be completed with each client and uploaded into the client’s chart.” Copies of the LIC 9172 for C1, C2, and C3 were not available for review. The following assessments were completed as follows:

Biopsychosocial Assessment – C1 (08/13/2024), C2 (09/24/2024), C3 (08/26/2024)
History and Physical Assessment – C1 (08/12/2024), C2 (09/20/2024), C3 (08/25/2024)
Psychiatric Evaluation – C1 (08/14/2024), C2 (09/20/2024), C3 (08/25/2024)
SRF Money and Food Management – C1 (08/15/2024), C2 (09/20/2024), C3 (08/28/2024)
Initial Nutrition Assessment – C1 (08/13/2024), C2 (09/24/2024), C3 (08/27/2024)

Regarding the allegation facility is not documenting the client’s progress in meeting goals, it was reported open client records for C1 and C2 did not contain documented evidence of ongoing review of progress towards reaching established goals.

Continued on LIC9099-C dated 5/30/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20241022091842
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: 05/30/2025
NARRATIVE
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LPA record review for C1 and C2 revealed C1’s treatment plan included the objective “Client will earn and practice at least x5 different ground skills over the next 30 days to reduce DES II score from 38.2 to 30.” In subsequential treatment notes, there is no mention on progress for client to reach their objective. C2’s treatment plan included the objective “Client will learn 5 skills to reduce the intensity of anxiety self-reporting a reduction in GAD-7 from 17 at intake to 14 by the next treatment plan review AEB assessment results.” In subsequential treatment notes, there is no mention on progress for client to reach their objective.

Regarding the allegation facility is not following plan of operation, it was reported facility was unable to provide documentation of policies and procedures as written and approved are being followed.

LPA record review of the program plan on file revealed for the Functional Needs Assessment, the facility will use the LIC9172 form for each client prior to accepting a client into treatment. The LIC7172 form for C1, C2, and C3 are not available for review by LPA.

Based on LPA record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 2), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 22-AS-20241022091842
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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2025
Section Cited
CCR
81068.2(b)
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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 was not met as evidence by
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Facility uses checklist to verify all assessments are completed within 72 hours. Facility provided LPA with a copy of the checklist.
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The facility did not ensure the needs and services plan for C2 was completed within 72 hours of admission which poses a potential health and safety risk to persons in care.
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Type B
06/27/2025
Section Cited
CCR
81069.2(a)
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Functional Capabilities Assessment
...The licensee shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing...
This requirement was not met as evidence by
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Facility to make changes to their online system to include a functional capabilities assessment as required by the Department. Licensee to send proof of change to LPA by POC due date.
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The facility does not use a functional capabilities assessment as required by the Department in determining functional capabilities for clients which poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20241022091842
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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2025
Section Cited
CCR
81022(j)
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Plan of Operation
The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so.
This requirement was not met as evidence by
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Facility to either incorporate LIC9172 into their intake procedures or provide their own form that meets the requirements for the Department. If using their own form, facility will update program plan and submit to Department for approval. Facility to submit proof to LPA by POC due date.
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The facility program plan states the LIC9172 will be completed for each client prior to admission. The facility does not complete the LIC9172 for clients admitted which poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7