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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006159
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:40:27 AM

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
10/15/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241015153423
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: 6DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ryan Reifsnyder, Anne Connor, Kristen RihaTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following its plan of operation
Facility staff did not properly complete clients’ assessments
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Administrator (AD) Ryan Reifsnyder, Program Director (PD) Anne Connor, and Clinical Director (CD) Kristen Riha, discussed the purpose of the inspection, and explained the allegations.

The investigation into the allegations that the facility is not following its plan of operation and facility staff did not properly complete clients’ assessments revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, PD, and CD, and obtained and reviewed copies of the resident roster, staff roster, the facility’s plan of operation, Client #1’s (C1) Biopsychosocial Assessment dated July 22, 2024, Client #3’s (C3) Biopsychosocial Assessment dated September 14, 2024, Client #2’s (C2) Treatment/Rehabilitation Plan dated September 30, 2024, C1’s Treatment/Rehabilitation Plan dated July 26, 2024, and C3’s Treatment/Rehabilitation Plan dated September 19, 2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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-20241015153423
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 - DEERHAVEN
FACILITY NUMBER: 306006159
VISIT DATE: 10/21/2024
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
26
27
28
29
30
31
32
Regarding the allegation that the facility is not following its plan of operation: it was alleged that a written assessment for C2 was not completed on admission, C1’s written assessments did not include medical needs, C3’s written assessments did not include meal planning, budgeting, and shopping skills as assessed on admission, C2’s Treatment/Rehabilitation Plan was not prepared with the client, and the Treatment/Rehabilitation Plans for C1, C2, and C3 did not include methods to evaluate achievement of goals. LPA inspected the facility and conducted health and safety checks on the clients present and observed no health and safety issues. LPA reviewed the facility’s plan of operation which states that clients’ assessments will include medical needs, meal planning, budgeting, and shopping skills, that clients’ Treatment/Rehabilitation Plans will be prepared with the clients and within 72 hours of admission, and that clients’ Treatment/Rehabilitation Plans will include methods to evaluate the achievement of goals. LPA reviewed C1’s Biopsychosocial Assessment dated July 22, 2024, which did not include medical needs. LPA reviewed C3’s Biopsychosocial Assessment dated September 14, 2024, which did not include meal planning, budgeting, and shopping skills as assessed on admission. LPA reviewed C2’s Treatment/Rehabilitation Plan dated September 30, 2024, which was completed late and not with the client because C2 was admitted on September 19, 2024. LPA reviewed C1’s Treatment/Rehabilitation Plan dated July 26, 2024, C2’s Treatment/Rehabilitation Plan dated September 30, 2024, and C3’s Treatment/Rehabilitation Plan dated September 19, 2024, which did not include methods to evaluate achievement of goals. LPA interviewed AD, PD, and CD who admitted the allegation and stated the facility has already taken measures to address these issues. The information obtained corroborated the allegation. Regarding the allegation that facility staff did not properly complete clients’ assessments: it was alleged that the Treatment/Rehabilitation Plans for C1, C2, and C3 were not completed within 72 hours of admission. LPA reviewed C1’s Treatment/Rehabilitation Plan dated July 26, 2024, which was completed more than 72 hours after C1’s admission on July 20, 2024. LPA reviewed C2’s Treatment/Rehabilitation Plan dated September 30, 2024, which was completed more than 72 hours after C2’s admission on September 19, 2024. LPA reviewed C3’s Treatment/Rehabilitation Plan dated September 19, 2024, which was completed more than 72 hours after C3’s admission on September 12, 2024. LPA interviewed AD, PD, and CD who admitted the allegation and stated the facility has already taken measures to address these issues. The information obtained corroborated the allegation.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. 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: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241015153423
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 - DEERHAVEN
FACILITY NUMBER: 306006159
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2024
Section Cited
CCR
81022(j)
1
2
3
4
5
6
7
81022 Plan of Operation (j) 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 evidenced by:
1
2
3
4
5
6
7
Licensee stated they will update their processes and forms to ensure client files contain all required information and will conduct staff training on completing the new processes and forms. Licensee stated they will submit proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on admission and documents, the licensee was not following its plan of operation when it did not properly complete the client files for 3 clients, which poses a potential health risk to persons in care.
8
9
10
11
12
13
14
Type B
11/18/2024
Section Cited
CCR
81068.2(b)
1
2
3
4
5
6
7
81068.2 Needs and Services Plan … (b) 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 evidenced by:
1
2
3
4
5
6
7
Licensee stated they will update their processes and forms to ensure needs and services plans are completed within 72 hours of admission and will conduct staff training on completing the new processes and forms. Licensee stated they will submit proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on admission and documents, the licensee did not ensure 3 client needs and services plans were completed within 72 hours of admission, which poses a potential health risk to persons in care.
8
9
10
11
12
13
14
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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3