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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881326
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:52:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20230615101243
FACILITY NAME:NEWPORT INSTITUTE - SYCAMOREFACILITY NUMBER:
331881326
ADMINISTRATOR:DOKES, KENYOTAFACILITY TYPE:
772
ADDRESS:28190 SYCAMORE MESA ROADTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY:6CENSUS: 2DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kenyota Dokes, Administrator
Michelle Hayes, Clinical Director		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff disclosed client's confidential information with unauthorized individual.
INVESTIGATION FINDINGS:
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On 6/21/2023, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation. LPA met with Administrator, Kenyota Dokes and Clinical Director, Michelle Hayes who was informed the purpose of the visit. At the time of visit, LPA interviewed staff, and reviewed resident record.
Regarding the allegation “Staff disclosed client's confidential information with unauthorized individual”, it was alleged staff disclosed resident’s confidential information to staff family member. LPA interviewed staff who acknowledged staff had a phone call discussing resident’s private medical information with staff family member present during the call.
Based on LPA’s, interview the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) is being cited on the attached LIC 9099D). An exit interview was conducted, and a copy of this report was reviewed with and provided to Kenyota Dokes.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20230615101243

FACILITY NAME:NEWPORT INSTITUTE - SYCAMOREFACILITY NUMBER:
331881326
ADMINISTRATOR:DOKES, KENYOTAFACILITY TYPE:
772
ADDRESS:28190 SYCAMORE MESA ROADTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY:6CENSUS: 2DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kenyota Dokes, Administrator
Michelle Hayes, Clinical Director, 		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not provide proper medication assistance to client in care.
INVESTIGATION FINDINGS:
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On 6/21/2023, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation. LPA met with Administrator, Kenyota Dokes and Clinical Director, Michelle Hayes who was informed the purpose of the visit. At the time of visit, LPA interviewed staff, and reviewed resident record.
Regarding the allegation “Staff did not provide proper medication assistance to client in care”, it was alleged staff administered an antibiotic, Doxycycline to resident without food. LPA interviewed staff who stated Doctor ordered Doxycycline should be taken 1 capsule by mouth twice daily. Staff stated Doctor’s order didn’t state medication should be taken with food. Resident’s Medication order and Medication Administration Record (MAR) was reviewed. Resident’s Medication order revealed one #1 capsule of Doxycycline should be taken by mouth twice daily, Resident MAR revealed Doxycycline was administered to resident as prescribed.
Based on LPA’s interviews with staff and resident record review, there is not enough evidence to support the above allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Kenyota Dokes.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20230615101243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - SYCAMORE
FACILITY NUMBER: 331881326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
81070(c)
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Client Records;

All information and records obtained from or regarding clients shall be confidential.
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Licensee stated moving forward staff will keep residents medical information confidential. Licensee stated the regulation cited will be reviewed with staff and a written statement of understanding of the regulation cited will be provided to LPA by the POC due date 6/30/2023.
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This requirement is not met based as evidence by interview. The licensee did not comply by having staff discussing resident’s private medical information with staff family member present which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3