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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881407
Report Date: 06/26/2023
Date Signed: 06/26/2023 11:06:28 AM

Document Has Been Signed on 06/26/2023 11:06 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEWPORT INSTITUTE-DEL MONTEFACILITY NUMBER:
331881407
ADMINISTRATOR:TBDFACILITY TYPE:
772
ADDRESS:41455 VIA DEL MONTETELEPHONE:
(714) 393-3523
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 0DATE:
06/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Kenyota DokesTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA), Cheryl Goodrich, conducted an announced pre-licensing inspection to the facility. The LPA met with Program Director Kenyota Dokes and Administrator Greg Young. There are currently zero (0) clients in care.

Application: The application is for an Adult Residential Facility (ARF). The fire clearance has been granted for six (6) ambulatory clients.

Buildings and Grounds: The home is composed of three (3) client bedrooms with two beds in each room, one (1) game room, three (3) bathrooms, a laundry area, kitchen and 2 dining areas (indoor and outdoor), a movie room, a computer room, sitting areas, and front/back yard area. The interior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Kenyota, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. The LPA tested the hot water temperature, which was registered at 105.2 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order.

Storage and Supplies: Medications will be stored on the second floor in the medications closet, inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a secured closet, which is located adjacent to the kitchen. Linens, and equipment appeared to be in good repair and sufficient for approved census. Fire extinguishers (3) were available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in the kitchen drawer, available only to authorized individuals. A 2-day supply of perishable and 7 day non-perishable food, and emergency food supplies present.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, Facility Sketch (LIC 999), Labor Law information and Visitor’s Policy.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with Kenyota and a copy of the report provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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