331881305-8-17-2023-18-AS-JSRS-CUT2RB-20230817173715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881305
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:37:19 PM

Document Has Been Signed on 08/17/2023 05:37 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- SHADY CREEK		FACILITY NUMBER:	331881305
ADMINISTRATOR:	LIPPELGOOS, SABRINA		FACILITY TYPE:	772
ADDRESS:	43821 SHADY CREEK		TELEPHONE:	(714) 393-3523
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92590
CAPACITY: 6		CENSUS: 6	DATE:	08/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Kenyota Dokes, Regional Program Director		TIME COMPLETED:	05:40 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) Jacqueline Shaw Ross arrived at the facility for the purpose of conducting a Annual visit. LPA Shaw Ross met with Kenyota Dokes, Regional Program Director and was informed of the purpose of today's visit. A tour of the facility was conducted inside and outside. The facility is approved for six (6) ambulatory residents. LPA Shaw Ross conducted staff and client interviews. The facility is a three (3) bedroom, five (5) bathroom one story home. There are two (2) clients to each bedroom and each bedroom has a private bathroom. There is also a room for overnight staff, a staff bathroom, as well as a public bathroom. In addition to three (3) bedrooms, the home also has a group room, nurses station, therapy room, family therapy room, kitchen, dining room, offices, backyard, laundry room, and recreation/art room. LPA Shaw Ross observed the residents' bedroom to be clean and appropriately furnished. Common areas such as dining and living rooms were observed to be clean and in good condition. LPA tested Smoke detectors and carbon monoxide units and all were found to be operable. Outdoor and indoor passageways are free of obstruction at the time of this visit. ADMINISTRATION/MEDICATION: LPA Shaw Ross observed a locked medication room with additionally locked cabinets where all medication is stored. Resident and staff records are electronic, and other physical records are locked and stored in staff office. LPA Shaw Ross observed monthly activity calendars. LPA Shaw Ross reviewed staff and resident files, and conducted three (3) staff interviews and three (3) resident interviews.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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- SHADY CREEK	FACILITY NUMBER: 331881305
	VISIT DATE: 08/17/2023

NARRATIVE

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Staff present have a criminal record clearance in file and are properly associated to the facility.

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 Shaw Ross tested the facility's hot water and observed it to be measuring at 113.7 degrees. Emergency drills are conducted quarterly.

ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. LPA Shaw Ross observed the backyard to be 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. Knives are kept locked and out of clients' reach for safety purposes, as well as cleaning and hazardous chemicals. 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 and posted in plain view at the facility and in each room. Facility was found to have operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Appropriate signage is posted throughout the facility.

OTHER ITEMS REVIEWED/DISCUSSED: Residents' medications were inspected for daily dispensing and are properly stored/dispensed according to physician's orders.

There were no deficiencies observed per Title 22, Div. 6, Chap 8. An exit interview was conducted, and a copy of this report and LIC811 was provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

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