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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881304
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:20:07 PM

Document Has Been Signed on 01/31/2024 02:20 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 ASC, 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: 6DATE:
01/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Somtochukwu Coleman - SupervisorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation for a complaint (#18-AS-20240122160521). Prior to arriving at the facility today, LPA Colvin conducted a review of the facility's status and observed that the Licensee is behind in paying their annual fees. As of today's date, the Licensee owes $908.00 for annual fees for 2023, as well as subsequent late fees. Due to this being the facility's first year of annual fees being due, LPA Colvin is issuing a Technical Violation in lieu of a deficiency. Supervisor Somtochukwu Coleman was advised to have the Licensee pay the outstanding fees right away to avoid a future deficiency for non-compliance.

Additionally, LPA Colvin observed that Somtochukwu Coleman is not associated to the facility, but has been working at this location since October 2023. Staff are required to have their fingerprint clearance transferred to a facility prior to working at the location. LPA Colvin will be issuing civil penalties in the amount of $500 ($100 a day x 5 days), as that is the maximum allowed.

An exit interview was conducted and a copy of this report, LIC809D, LIC421BG, LIC9102-TV, and appeal rights was provided to Supervisor Somtochukwu Coleman.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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Document Has Been Signed on 01/31/2024 02:20 PM - It Cannot Be Edited


Created By: Crystal Colvin On 01/31/2024 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NEWPORT INSTITUTE -PATAGONIA
FACILITY NUMBER: 331881304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
81019(e)(2)

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Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 81019(f)... This requirement was not met by:
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Licensee agrees to have S1's criminal record clearance trasnferred to the facility immediately. Licensee may self-certify to LPA Colvin once complete.
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Based on interview and record review, the Licensee did not comply with the above requirement with one staff member (S1). S1 has been working at this location since October 2023, but is not associated to the facility. This is an immediate safety risk
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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