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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881305
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:35:04 PM

Document Has Been Signed on 08/02/2024 03:35 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- SHADY CREEKFACILITY NUMBER:
331881305
ADMINISTRATOR/
DIRECTOR:		LIPPELGOOS, SABRINAFACILITY TYPE:
772
ADDRESS:43821 SHADY CREEKTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 6CENSUS: 5DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Sabrina Lippelgoos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 08/02/24 at 1:05pm Licensing Program Analyst (LPA) Javina George made an unannounced visit for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Administrator Sabrina Lipplegoos and informed of the purpose of today's visit. Based on the fire Clearance, the facility is licensed to serve six (6) ambulatory residents on 7/29/22 by the Riverside County Fire Department. The home is set-up with group/blue room, therapy room, family therapy room, kitchen, dining room, three (3) resident bedrooms, (6) restrooms, (4) offices, backyard, laundry room, gym, Learning lab, art closet, IT room, staff/CC room, recreation/art room and medication room.

Infection Control:The facility was observed to have an adequate supply of Personal Protective Equipment (PPE) supplies.

Physical Plant: LPA conducted a tour of the interior and exterior areas of the facility. The facility has a black bottom pool, with a spa and water slide. The pool is surrounded with a gate which is locked and monitored by staff during resident use. Exits to the outside were observed to be from obstruction and unlocked for residents' and staff's use in case of emergency. The facility does not have a secured perimeter and there are no locked gates around the facility restricting emergency exit. LPA observed required accommodations in residents' bedroom and bathrooms, including beds, linen, storage furniture, and lamps.

Records Review: Staff Records: The facility utilizes an electronic record keeping system and observed that there are sufficient staff present to meet the needs of the residents. The staff present were observed to have obtained criminal record clearance and to be associated to the facility.

Resident Records: A review of all (5) current residents files were observed to have Physician's Report, Admissions Agreement and several other assessments.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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- SHADY CREEK
FACILITY NUMBER: 331881305
VISIT DATE: 08/02/2024
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Medication: The medications are stored in a locked medication room with additionally locked cabinets that houses the medications, that were observed to be in individual storage containers. The facility also utilizes an electronic Medication Authorization Record (MAR).

Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for resident’s use. The facility has the meals that are prepared by a chef. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts regular disaster drills on a monthly basis. The last drill was conducted on 07/25/24. The dual smoke and carbon monoxide detectors were tested and were found to be operable. The facility has fully charged fire extinguishers, that are checked on a monthly basis. There are no known guns or ammunition on the premises. LPA observed for the facility to possess a Department of Health Care Services certificate which expires on 08/22/24. The facility was observed to have a waiver for Clinical Laboratory Improvement amendments that expires on 08/28/25. In addition the facility's Clinical and Public Health Laboratory License is valid until 08/28/24.

Based on today's inspection no deficiencies were cited.

An exit interview was conducted and a copy of this report, were provided to Sabrina Lippelgoos, Administrator.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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