<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881326
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:46:23 AM

Document Has Been Signed on 11/15/2022 11:46 AM - 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 - SYCAMOREFACILITY NUMBER:
331881326
ADMINISTRATOR:DOKES, KENYOTAFACILITY TYPE:
772
ADDRESS:28190 SYCAMORE MESA ROADTELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 6CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR, MATT NONOSHITATIME COMPLETED:
12:00 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
On November 15,2022, Licensing Program Analyst (LPA) Venus Mixson conducted a scheduled visit for the purpose of conducting a pre-licensing inspection. LPA met with Administrator, Matt Nonoshita and was shown the facility inside and outside. Facility is a two story facility with (3) bedrooms, (5) offices, (61/2) restrooms, a living room, dinning area, kitchen, and three car garage with backyard. On October 27, 2022, Riverside County Fire Department approved the facility for 6 ambulatory, 0 non-ambulatory, and 0 bedridden. During today's inspection, LPA Mixson toured the interior and exterior of the facility. The area for medications were centrally stored and locked inside a medication closet. The facility is equipped with lights in the passages. The facility is also stocked with emergency night lights throughout the facility. The smoke and carbon monoxide detectors were tested and are operable. There were 19 fire extinguishers observed. LPA Mixson observed all fire extinguishers. All cleaning supplies are locked in laundry area. The sharp objects are locked in a kitchen drawer. All doors, and passageways are clear from obstruction. There was a pool with a fences, and a jacuzzi in closed on the premises. All beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand and chair. LPA Mixson observed central heating and air conditioning systems. The Administrator dialed out on the land line phone number (951) 308-1551. Outside/Yards: No obstructions observed. Component III reviewed.
An exit interview was conducted, a copy of this report was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1