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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006158
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:23:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2023 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231026141301
FACILITY NAME:NEWPORT INSTITUTE - MIRAMARFACILITY NUMBER:
306006158
ADMINISTRATOR:INNERS, HEATHERFACILITY TYPE:
772
ADDRESS:10022 MIRAMAR CIRCLETELEPHONE:
(714) 393-3523
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 6DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Matthew Gomer- Residential Director
Crystal Goodwin- Licensing/Compliance Manager		TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility did not complete the clients' admission agreements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to conduct the complaint investigation visit into the above allegation. LPA announced self and stated the purpose of the visit to Residential Director (RD) Matthew Gomer. LPA interviewed staff and obtained copies of pertinent records for six clients during the visit. The following was revealed during the course of the investigation:

It is alleged that the facility did not complete the clients' admission agreements. LPA reviewed six out of six admission agreements and observed one out of the six admission agreement was not signed by Client #1 (C1) within the seven day period upon C1's admission on October 17, 2023. Therefore, it is determined that the facility did not complete C1's admission agreement as observed on today's date.

Based on LPA's observations, interview, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 2 ...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 3
Control Number 22-AS-20231026141301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - MIRAMAR
FACILITY NUMBER: 306006158
VISIT DATE: 11/02/2023
NARRATIVE
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of the California Code of Regulations is being cited on the attached LIC 9099D.

An exit interview was conducted with Residential Director Matthew Gomer and Licensing/Compliance Manager Crystal Good by telephone, and a copy of this report including the LIC9099-C LIC-,811, LIC9099-D, and the appeal rights were provided at the end of the visit.


SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20231026141301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - MIRAMAR
FACILITY NUMBER: 306006158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
81068(d)
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81068 Admission Agreements (d) Such agreements shall be dated and signed, acknowledging the contents of the document, by the client and the client's authorized representative and the licensee or the licensee's designated representative no later than seven calendar days following admission. This requirement was not met as evidenced by:
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Residential Director stated they they will ensure all clients admission agreements are signed moving forward and to submit a signed copy of C1's admission agreement and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
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Based on LPA's observations, interview, and review of records, the admission agreement was not signed by C1 which poses a potential Health, Safety, and Personal Rights 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: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3