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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881304
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:18:21 PM

Document Has Been Signed on 09/15/2023 03:18 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEWPORT INSTITUTE -PATAGONIAFACILITY NUMBER:
331881304
ADMINISTRATOR:SEIFSNYDER, RYANFACILITY TYPE:
772
ADDRESS:39650 PATAGONIA COURTTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 3DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Clinical Director Michelle HayesTIME COMPLETED:
03:19 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 12:25 p.m. to conduct an unannounced annual visit. LPA met the with Caregiver Mary at the front door and was granted entry. The Clinical Director Michelle Hayes arrived 12:52 p.m. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) ambulatory residents with 3 ambulatory residents in care.
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 74 degrees. The facility consists of 3 resident bedrooms, and 3 bathrooms, living room, kitchen, gym, recreational area, theatre and backyard. The bedrooms are furnished with, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 120 degrees within regulation requirements. The living room and kitchen are clean and clear of obstruction. The medications are stored in a locked cabinet in the clinical area near the nurses station and inaccessible to residents. The SRF and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order.
Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.
Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, psychiatric evaluation, client rights, and admissions agreement.

(Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEWPORT INSTITUTE -PATAGONIA
FACILITY NUMBER: 331881304
VISIT DATE: 09/15/2023
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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has electronic and paper medication logbook, and the facility documented the resident’s medication and in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 07/07/23 at 6:15 a.m. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Clinical Director Michelle Hayes and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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