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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006159
Report Date: 08/16/2023
Date Signed: 08/16/2023 11:32:04 AM

Document Has Been Signed on 08/16/2023 11:32 AM - 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 - DEERHAVENFACILITY NUMBER:
306006159
ADMINISTRATOR:CHAPMAN, KANANFACILITY TYPE:
772
ADDRESS:9881 DEERHAVEN DRIVETELEPHONE:
(714) 393-3523
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 4DATE:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Chris Brown, Kanan ChapmanTIME COMPLETED:
11:45 AM
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 08/01/23 regarding an incident of self-harm and harm to another client involving Client #1 (C1) and Client #2 (C2). LPA met with Staff #1 (S1) Chris Brown and discussed the purpose of the inspection. Administrator (AD) Kanan Chapman arrived during the inspection.

The incident report states that on 07/31/23, C1 took a knife that they had put on the burner in the kitchen, placed it on their arm and then C2’s arm, which resulted in noticeable burn marks on both clients. The incident was not observed by staff but staff were made aware of the incident by another client. Both clients were provided medical treatment and staff were instructed that clients were no longer allowed in the kitchen without a staff present.

During today’s inspection, LPA observed 4 clients and 4 staff present. LPA conducted health and safety checks on C1 and C2, confirmed they were doing well, and observed no health and safety issues. LPA observed the burn marks on C1 and C2 had healed and appeared minor. C2 did not blame C1 for the incident and C1 stated it was an impulse and felt sorry. LPA and S1 inspected the inside and outside of the facility, including all rooms. LPA observed all sharps, toxins, and medications were properly stored, and observed no health and safety issues. The kitchen only contained butter knives and no sharp knives. Sharp knives are secured in a locked cabinet inside the staff office which is locked.

LPA interviewed AD who provided the following information. The knife used was a butter knife, the burn was assessed by the nursing team which determined urgent care was not necessary, neither client has a history of self-harm or violence, at intake the facility conducts 3 levels of screenings to assess the safety risk of all clients, and there have been no further incidents with these clients. There are 3 direct care staff per day shift and at the time of the incident the facility had 4 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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 08/16/2023 11:32 AM - It Cannot Be Edited


Created By: Sean Haddad On 08/16/2023 at 11:13 AM
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 - DEERHAVEN
FACILITY NUMBER: 306006159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
81078(a)

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81078 Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated that a new protocol has been established that clients are not allowed in the kitchen without staff supervision and all staff have been trained on this new protocol. Licensee stated they will provide proof to LPA by POC due date.
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Based on interview and documents, the licensee did not ensure C1 and C2 received care and supervision when C1 used a hot butter knife to burn themselves and C2, which posed 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - DEERHAVEN
FACILITY NUMBER: 306006159
VISIT DATE: 08/16/2023
NARRATIVE
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Since this incident, the new protocol is that clients are not allowed in the kitchen without staff supervision.

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: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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