331881326-11-29-2023-18-AS-CNWE-CY2S3B-20231129123051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881326
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:31:04 PM

Document Has Been Signed on 11/29/2023 12:31 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 - SYCAMORE		FACILITY NUMBER:	331881326
ADMINISTRATOR:	DOKES, KENYOTA		FACILITY TYPE:	772
ADDRESS:	28190 SYCAMORE MESA ROAD		TELEPHONE:	(714) 393-3523
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92590
CAPACITY: 6		CENSUS: 3	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Kenyota Dokes, Administrator Michelle Hayes, Clinical Director Lauren Larkin, House Manager		TIME COMPLETED:	12:40 PM

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On 11/29/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Care Coordinator, Alice Arana who was informed of the purpose of the visit. LPA also met with Administrator, Kenyota Dokes, Clinical Director, Michelle Hayes and House Manager, Lauren Larkin who were also informed of the purpose of visit. At the time of visit there were three #3 residents present. LPA toured the facility inside and out with Lauren Larkin and Michelle Hayes.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked safe in the kitchen, available only to authorized individuals. Trash cans has tight-fitting lids. Fridge, Freezer and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 75 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications: LPA observed medications were labeled and stored inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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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Document Has Been Signed on 11/29/2023 12:31 PM - It Cannot Be Edited

Created By: Chinwe Nwogene On 11/29/2023 at 11:55 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81087(j)

Buildings and Grounds

(j) All licensees serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by leaving the pool gate open making the pool accessible to client which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	LPA observed the House Manager immediately locked the pool gate.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Chinwe Nwogene

LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 - SYCAMORE	FACILITY NUMBER: 331881326
	VISIT DATE: 11/29/2023

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Continued from LIC809.

Bathroom: LPA toured two #2 resident bathrooms and observed bathrooms to be clean and equipped with non-slip mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 114 degrees Fahrenheit.

Bedroom: LPA toured three #3 out of #3 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident bedroom #2 and #3 has private bathrooms. LPA observed bathrooms to be clean and hot water was measured at 114 degrees Fahrenheit.

Garage: LPA tour the garage and observed garage to be clean.

Laundry: Washing machine and dryer are all in good repair and sufficient for the census. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. Facility has a pool. LPA observed pool was not adequately secured (citation will be issued).

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and Freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

Interview: Three staff and three residents were interviewed.

Therefore, based on the observations made during today’s visit, one #1 deficiency will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC809-D. An exit interview was conducted, and this reported was provided along with appeal rights to Kenyota Dokes.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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