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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881305
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:13:29 PM

Document Has Been Signed on 08/16/2022 12:13 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- SHADY CREEKFACILITY NUMBER:
331881305
ADMINISTRATOR:TO BE DETERMINEDFACILITY TYPE:
772
ADDRESS:43821 SHADY CREEKTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 6CENSUS: 0DATE:
08/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Matt Nonoshita - ApplicantTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit. Analyst met with Applicant Matt Nonoshita, who LPA Colvin informed of the purpose of today's visit, and toured the facility with the applicant.

Fire Clearance was granted for six (6) ambulatory residents on 7/29/22 by the Riverside County Fire Department. The home is set-up with group room, therapy room, family therapy room, kitchen, dining room, three (3) resident bedrooms, restrooms, offices, backyard, laundry room, and recreation/art room.

LPA Colvin observed required accommodations in residents' bedroom and bathrooms, including beds, linen, storage furniture, and lamps. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when applicant tested them. Common areas such as dining and living rooms were observed to be clean and in good condition.

ADMINISTRATION/MEDICATION: A locked medication room with additionally locked cabinets is present and where all medication is stored. Resident and staff records will be electronic, but any other physical records will be locked in staff office. Medication room includes locked PRN OTC medication for which the Applicant stated the residents' doctors will have a standing order and each resident will have their own OTC PRN medication bottles.

PHYSICAL PLANT: Outside premises were inspected for potential hazards. The facility grounds includes a pool which is surrounded with a gate which is locked and monitored by staff during client use. Exits to the outside were observed to be unlocked for clients' and staff's use in case of emergency, and there are no locked gates around the facility restricting emergency exit. LPA Colvin tested the facility's hot water and observed it to be measuring at 121.2 degrees. LPA Colvin advised the applicant to lower the temperature of the hot water heater slightly to help ensure it does not exceed 120 degrees but is at least 105 degrees.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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- SHADY CREEK
FACILITY NUMBER: 331881305
VISIT DATE: 08/16/2022
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ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with outdoor furniture and a shaded area for the residents. Facility additionally has magazines, tv, books, games, art supplies, garden, and exercise equipment for residents' use.

FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Trash can has tight-fitting lid. Dishes, utensils and glasses are present and in sufficient number for residents and staff. Dishwasher will be used to clean and sanitize dishes. Knives will be kept locked and out of clients' reach for safety purposes, as well as cleaning chemicals. All need appliances were present and shown to be in working condition and clean. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7-day requirements.

EMERGENCY EXIT PLAN: Facility has an emergency exit plan in place a posted in plain view at the facility and in each room with the current room highlighted. Facility was found to have operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Applicant has completed and submitted a Mitigation Plan for Infection Control for the facility as well.

Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant's passing of the inspection..

An exit interview was conducted with Applicant Matt Nonoshita and a copy of the report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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