306006159-9-28-2022-22-AS-MRED-CJPSP2-20220928140224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006159
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:02:39 PM

Document Has Been Signed on 09/28/2022 02:02 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 - DEERHAVEN		FACILITY NUMBER:	306006159
ADMINISTRATOR:	CHAPMAN, KANAN		FACILITY TYPE:	772
ADDRESS:	9881 DEERHAVEN DRIVE		TELEPHONE:	(714) 393-3523
CITY:	NORTH TUSTIN	STATE: CA	ZIP CODE:	92705
CAPACITY: 6		CENSUS: 4	DATE:	09/28/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kanan Chapman, Anne Conner and Matthew Gomer		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Michelle Reed conducted an announced pre-licensing visit and was greeted by Residential Director Matthew Gomer and Designated Administrator Kanan Chapman. Program Director Anne Conner arrived at approximately 1:15pm. Prior to being granted entry into the facility, staff took LPA's temperature and provided a sign in sheet.

The initial application to operate a Social Rehabilitation Center was submitted to the Central Applications Bureau (CAB) on 2/28/22 for a capacity of 6 ambulatory residents. A tour of the physical plant was conducted inside and out with Mr. Gomer and Mr. Chapman. The following was observed:

There were a total of 4 residents in care participating in group activities and a total of 3 staff on duty. Human resources will complete the associations via Guardian.

Structure: Facility is a single story house. On 3/16/22, the Orange County Fire Authority granted a fire clearance for a capacity of 6 ambulatory residents. There are a total of 3 shared bedrooms, 5 bathrooms and the master bedroom is used for therapy sessions. There are no single rooms. There is also a direct care office and a counseling and therapist office.

Bedrooms: All three bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: The bathrooms were observed to be in good repair, toilets were operational, and non-skid floor mats were provided. Water temperature in restrooms was measured to be at 118 degrees Fahrenheit and hand washing signs were observed along with soap and paper towels.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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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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: 09/28/2022

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Linens and Hygiene Supplies: Facility has an adequate supply of linens

Posters, Emergency Phone Numbers, Exit Plan: LPA observed the COVID-19 precautionary signs posted, along with the PUB475 "See Something, Say Something" poster. Emergency disaster plan is posted at the entrance of the facility.

Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Facility had back-up emergency food and water supply.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide detectors were tested and operational.

Alarms: There are auditory alarms located on every door and window of the facility.

Fire Extinguisher: Fire extinguishers are located in multiple areas of the facility and observed to be charged and mounted.

Appliances: Stove is a four-burner induction stove, there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the laundry room.

Toxins: Toxins and disinfectants are locked and inaccessible to residents.

Medications, PPE First-Aid Kit and Manual: LPA observed that First Aid Kits had all the required components. Medications were locked in a medication room. Facility had an adequate supply of PPE.

Backyard: There are 2 exit gates in the backyard, and facility will ensure that both gates are self-latching and self-closing. There are no bodies of water. Shade and outdoor seating was also observed.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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: 09/28/2022

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Resident and Staff Files: Records are kept via computer record using the Lightning Step program

Recreational Activities: The facility has activities that coincide with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit. Information discussed on how to operate the facility within compliance.

The Pre-licensing is complete and the facility has no deficiencies for correction.

The License will be effective upon receipt of the Mental Health Certification. The Department reserves the right to modify and provide further instructions once the Plan of Operation is reviewed. An exit interview was conducted with Applicant Representatives and a copy of this report was provided to Kanan Chapman.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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