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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001719
Report Date: 06/25/2021
Date Signed: 06/25/2021 10:55:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 4DATE:
06/25/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Rojel NinoblaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Melana Llopis arrived unannounced at the facility on 06/25/2021 to conduct a Plan of Correction (POC) visit from complaint visit on 06/14/2021. LPA was granted entry by staff, Rojel Ninobla who made Administrator aware of LPA's presence.
Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by Rojel Ninobla, staff, upon entering the facility.

LPA inspected each exit door and found auditory devices to monitor exits were in working order.

POC was cleared as a result of today's visit.

Exit interview conducted with Administrator via telephone. Copy of report provided and POC letter printed.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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