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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850157
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:01:33 PM

Document Has Been Signed on 09/22/2021 01:01 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NEWPORT INSTITUTE - PIMLICOFACILITY NUMBER:
565850157
ADMINISTRATOR:STOKES, JEBFACILITY TYPE:
772
ADDRESS:10813 PIMLICO DRIVETELEPHONE:
(714) 393-3523
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 0DATE:
09/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Jeb Stokes and Crystal GoodwinTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Pre-licensing visit at the facility. LPA met with Administrator Jeb Stokes and Applicant Representative Crystal Goodwin. On 9/17/21 LPA received a letter from the Applicant Representative Joseph Procopio designating Crystal Goodwin as the Applicant Representative for the Prelicensing visit. Crystal Goodwin attended Component III on 3/16/21 during a Prelicensing visit for Newport Academy-Alberca #565802317. LPA observed that the facility is located in a gated community.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. Facility has adequate linen, first aid supplies and nonperishable food supplies.

Facility has 3 shared client bedrooms and 2 shared client bathrooms. The laundry supplies and equipment are kept in a laundry room. There is sufficient indoor and outdoor space for activities. Facility has 1 staff bathroom and 2 visitor/client bathrooms. The common areas were appropriately furnished and lighting was adequate. There is additional entertainment equipment and games for activities. The medications are kept in a locked medication room. Resident records will be kept electronically. Staff records will be kept in an outside office location and also electronically. Hot water temperature tested at 117.2 degrees Fahrenheit during today’s visit. LPA observed hard wired smoke detectors and carbon monoxide detectors operating properly. LPA observed fire extinguishers properly charged. LPA observed gated and locked swimming pool in backyard area. Fire clearance is approved for 6 ambulatory clients.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Proof a working telephone

Exit interview conducted, today's report was reviewed and emailed to the Applicant Representative.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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