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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001719
Report Date: 02/02/2021
Date Signed: 02/02/2021 12:10:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NEWPORT HOMEFACILITY NUMBER:
315001719
ADMINISTRATOR:KIM, AUSTINFACILITY TYPE:
740
ADDRESS:1123 NEWPORT WAYTELEPHONE:
(916) 784-0111
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
02/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Austin Kim TIME COMPLETED:
10:00 AM
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On February 2, 2021 at 9:30 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Administrator, Austin Kim, via telephone to conduct an unannounced Case Management visit. This visit was conducted via telephone due to COVID-19 and pre-cautionary measures.

The purpose of the telephone call was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 01/31/2021. The report indicates that a resident (R1) returned from the hospital and refuses to enter the facility. R1 was agitated and wandering around the facility screaming. Caregiver was unable to calm R1 down and called administrator for assistance. Administrator reached out to R1's POA and notified POA of the situation. Administrator stated the hospital discharged R1 without proper paperwork and medications. Due to R1 being without medication for four days, Administrator and POA decided to send R1 to Sutter Hospital. Administrator stated he spoke to R1's POA and placement agency that the facility is unable to meet R1's needs. POA and placement agency were looking for another facility for R1. Sutter Hospital called Administrator and stated they were going to discharge R1 back to the facility. Administrator told Sutter Hospital that R1 needs higher level of care and the facility cannot provide that for R1. Administrator refused to accept R1 back to the facility.

LPA interviewed Austin Kim regarding the report. The interview indicates that R1 did not return to the facility. POA was able to find another facility for R1. LPA requested for R1's physician report, medical records, discharge documents, and plan of care.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Administrator, Austin Kim, was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
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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