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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006158
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:56:05 PM

Document Has Been Signed on 10/18/2023 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 - MIRAMARFACILITY NUMBER:
306006158
ADMINISTRATOR:INNERS, HEATHERFACILITY TYPE:
772
ADDRESS:10022 MIRAMAR CIRCLETELEPHONE:
(714) 393-3523
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
10/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Autumn Carter, Care Coordinator IIITIME COMPLETED:
02:30 PM
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Ruth Martinez for the purpose of following on a self-reported incident report received on October 04, 2023 regarding a medication error involving Client #1 (C1) that took place on October 04, 2023. LPA arrived at facility was greeted and granted entry by staff. LPA met with Autumn Carter, Care Coordinator III and explained the nature of the visit.

The incident report states the following: On October 04, 2023, C1 was given the wrong dose of medication, C1 had no adverse reaction to incident, C1 was monitored and was given a set of vitals, and all required responsible parties were notified. C1 did not need additional medical treatment.

During today’s inspection, LPA was informed C1 was discharged on October 17, 2023 and LPA observed no health and safety issues. LPA interviewed staff #1 (S1) regarding the incident. LPA was informed facility immediately following the incident was retrained by facility Nurse and shadowed for S1's shift on medication distribution.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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 10/18/2023 01:56 PM - It Cannot Be Edited


Created By: Ruth Martinez On 10/18/2023 at 01:31 PM
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 - MIRAMAR
FACILITY NUMBER: 306006158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
81075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on observation and records, the licensee did not ensure C1 received the the proper mediation dose as prescribed, as
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Facility will provide medication training on regulation cited to all staff handling the medications. Proof of training will be provided to LPA Martinez on or before POC due date.
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C1 was given an inproper dose of medication which poses an immediate 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
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