<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006158
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:08:48 PM

Document Has Been Signed on 11/02/2023 02:08 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
CCLD Regional Office, 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: 6DATE:
11/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Amber Wofford- Residential SupervisorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jessica Cho continued the visit after observing a deficiency while conducting a complaint investigation in connection to Complaint Control Number: 22-AS-20231026141301. LPA explained the purpose of this Case Management-Deficiencies visit to Residential Supervisor Amber Wofford.

While investigating the complaint investigation mentioned above, LPA met with Residential Director (RD) Matthew Gomer upon entry at 9:17am and verified with RD Gomer approximately 9:30am that Staff #1 (S1) was not listed on the Department's Licensing Information System (LIS) Facility Personnel Report Summary and the Guardian Employee Roster. LPA verified that S1 was fingerprint cleared and associated to two other facilities operated by the licensee. S1 was associated during the visit, however the determination status was pending at this time, therefore the preponderance of evidence standard has been met for S1 as the facility did not ensure that S1 was associated as required by the Title 22 Regulations, 81019 Criminal Record Clearance. LPA observed S1 leaving the facility at 12:30pm.

A deficiency is being cited per Title 22, Division 6, Chapter 2 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted with Residential Supervisor Amber Wofford, authorized by Licensing/Compliance Manager Crystal Goodwin, and a copy of this report including the LIC809D, LIC421BG, LIC811, 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/02/2023 02:08 PM - It Cannot Be Edited


Created By: Jessica Cho On 11/02/2023 at 01:28 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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
81019(e)(2)

1
2
3
4
5
6
7
81019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide proof of association of S1 and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.
8
9
10
11
12
13
14
Based on LPA's observations, interviews, and review of records, S1 was not associated and cleared to be working at the facility as it was pending review at the time of the visit which poses an immediate Health, Safety, or Personal Rights 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 2