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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850157
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:32:32 AM

Document Has Been Signed on 10/18/2022 11:32 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NEWPORT INSTITUTE - PIMLICOFACILITY NUMBER:
565850157
ADMINISTRATOR:STOKES, JEPFACILITY TYPE:
772
ADDRESS:10813 PIMLICO DRIVETELEPHONE:
(805) 523-2294
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 3DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Alex Hernandez, Residential SupervisorTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Annual Inspection at the facility today, with an emphasis on Infection Control practices and procedures. LPA arrived at 10:20AM and met with Residential Supervisor Alex Hernandez. Entrance interview conducted. A tour of the physical plant was conducted with Alex Hernandez at 10:22AM and the following observed:

Fire extinguishers located throughout the facility were observed to be fully charged and last serviced on 07/20/2022. Report for the fire inspection conducted on 07/26/2022 was reviewed; no violations were noted.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable and nonperishable food observed. Cleaning supplies are stored in locked. Knives and other sharps were observed to be inside a locked office. There were no visible immediate hazards observed.

SURROUNDING GROUNDS: The Front Yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, shade and an in-ground swimming pool. The pool is kept inaccessible to clients with the use of fencing that includes a locked gate. Facility staff indicated clients use the pool occurs on the weekends, when properly supervised. There were no visible immediate hazards or deficiencies.

COMMON AREAS: These include the Family Room, Living Room, Dining Room, and Laundry Room. The common areas were furnished appropriately and all furniture was observed to be in good condition. There is a fireplace in the Living Room, which was observed to be adequately screened. Locked Laundry Room is located on the ground floor. Laundry and cleaning supplies were observed in locked cabinets inside the locked Laundry Room. There were no immediate hazards observed
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157
VISIT DATE: 10/18/2022
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TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group/Family Room, a Work Lab/Classroom, Work Station and 2 (two) Offices located on the ground floor. Medications are stored in a locked first floor Medication Room. The medication room has adequate locked storage. The 1st Aid Kit is stored in the Medication Room. There is also a Family Therapy/Group Room located on the second story. The Offices are kept inaccessible to clients unless properly supervised.

BEDROOMS: There are three (3) Bedrooms, all of which are designated for client use. All bedrooms are located on the second story and furnished for double occupancy. All bedrooms were equipped and supplied with appropriate furniture, bedding and linens. There were no visible hazards observed.

BATHROOMS: There are four (4) Bathrooms, one (1) on the ground floor and three (3) on the second floor. The bathroom located on the ground floor is designated for client use. The bathrooms located on the second floor are all full bathrooms and two (2) are designated for client use. 1 upstairs bathroom is designated for staff use only. All Bathrooms were supplied with appropriate soap and paper towels. Water temperatures was measured in client bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit.

INFECTION CONTROL: During today's visit, LPA spoke with Residential Supervisor regarding the facility's infection control policies and procedures. Upon entry, the facility has a central entry point. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendation was made:
- N95 fit testing for all staff

No deficiencies cited. Exit interview conducted with Residential Supervisor Alex Hernandez. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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