331881304-9-19-2022-18-AS-YDEO-CJESTN-20220919140948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881304
Report Date: 09/19/2022
Date Signed: 09/19/2022 02:10:04 PM

Document Has Been Signed on 09/19/2022 02:10 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NEWPORT INSTITUTE -PATAGONIA		FACILITY NUMBER:	331881304
ADMINISTRATOR:	SEIFSNYDER, RYAN		FACILITY TYPE:	772
ADDRESS:	39650 PATAGONIA COURT		TELEPHONE:	(714) 393-3523
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY: 6		CENSUS: 0	DATE:	09/19/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ryan Seifsnyder, Administrator		TIME COMPLETED:	02:15 PM

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	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:40 AM, LPA met with Administrator Ryan Seifsnyder, Kenyota Dokes, Program Director, Jerome Spurlin, Compliance Specialist, Matt Nonoshita, Executive Director/Licensee. An initial application to operate a Social Rehabilitation Facility was submitted to the Central Applications Bureau (CAB) on 7/11/2022 for a total capacity of six (6) ambulatory. Fire clearance was granted on 8/30/2022. LPA Delgado observed the following: Structure: Facility was a three-story house with three (3) resident bedrooms, five (5) resident bathrooms, living room, family room, dining area and kitchen, therapy rooms on the Main 1st floor. There was an attached three car garage on the the west side of the house. Main House 2nd floor-two (2) offices. Basement-Recreation room, Exercise room, theater room, Art Space, Storage, one (1) bathroom. Garage for Main House is used for extra storage space for Chef and sink is non-operational and is not in use. Guest House is a two-story for Administration use only. Heating/Cooling System: Central heating and air conditioning system installed with 8 thermostats located in Basement-two (2) hallway that lead to Recreation room and Art Space. Main House-1st floor two (2) in hallway. Main House 2nd floor in resident room, two (2) in hallway. Bedrooms: Each resident bedroom #1, #2, and #3 will accommodate any ambulatory resident. 3 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NEWPORT INSTITUTE -PATAGONIA	FACILITY NUMBER: 331881304
	VISIT DATE: 09/19/2022

NARRATIVE

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(CONTINUED FROM LIC 809)

Bathrooms:
The five (5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 11:11 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured between 75.7 degrees and 125 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in the laundry room and underneath the sink secured/locked away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
Hygiene supplies observed on the 2nd floor inside a closet but no supply of linens was observed.
Yards/Outside:
Patio table and sufficient chairs were observed in the backyard. There is sliding gate to the front of the property that is automatic and accessed after hours with code. All outdoor pathways were free of obstructions.

(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NEWPORT INSTITUTE -PATAGONIA	FACILITY NUMBER: 331881304
	VISIT DATE: 09/19/2022

NARRATIVE

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(CONTINUED FROM LIC 809-C)

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in resident bedrooms, bathrooms and through out the facility. Let-Us-No poster observed.
General items:
Twelve (12) fire extinguishers were charged and located throughout the Main house. Twenty (20) smoke alarms/carbon monoxide detectors were tested and were observed to be in working order. Client records are stored electronically. Staff records will need to be requested through Corporate. First Aid kit with required components, and Med Room is for medication storage was observed. LPA observed a facility phone and it was verified to be non-operational as evidenced by LPA dialing the number and it did not trigger a ring. Emergency water supply and emergency food was observed. Component III was completed on this day as well. LPA suggested facility to obtain additional PPE supplies.

(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NEWPORT INSTITUTE -PATAGONIA	FACILITY NUMBER: 331881304
	VISIT DATE: 09/19/2022

NARRATIVE

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(CONTINUED FROM LIC 809-C)

Pre-Licensing is incomplete and the following corrections to be resolved by 9/21/2022:

Update Facility sketch to include the garage that will be used for Learning/Lab, bathroom, kitchenette
Update Facility sketch for Guest House that will be strictly used for Administration
obtain lidded trash cans for sink area
obtain licensed plumber to verify all sinks and showers in main house for water temperature to be between 105-120 degrees
obtain additional linen for bedding

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

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