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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850157
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:34:31 PM

Document Has Been Signed on 10/05/2023 04:34 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, JEPFACILITY TYPE:
772
ADDRESS:10813 PIMLICO DRIVETELEPHONE:
(805) 523-2294
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Charles Jimenez / Megan MewTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived unannounced to conduct a one year required annual inspection today at 9:45 a.m. The last annual conducted at this facility was on 10/18/2022. When the LPA arrived, there were six staff and four clients present. The LPA was greeted at the door by the Lead Care Coordinator, Anna Sanamyan and at this time, the reason for the visit was explained. The Residential Supervisor, Charles Jimenez and Compliance Specialist, Regan Mew arrived during the inspection. Entrance interview conducted.

The LPA along with the lead care coordinator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 10:05 a.m. At 10:07 a.m., the hot water temperature was measured in the kitchen at 116.2 degrees Fahrenheit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. Knives and sharps are locked in the staff room. Cleaning supplies and disinfectants are stored under the kitchen sink inaccessible to clients.

COMMON AREAS (TREATMENT/THERAPY/OFFICE AREAS): At the time of the visit, treatment, therapy, and office furniture was observed to be in good condition. The LPA observed clients in common areas reading at the time of the inspection. Activities are both designed for both as individuals and as a group. The facility maintained a comfortable temperature. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 07/08/2023. The LPA observed required postings throughout the common space. There is a separate laundry room, which is kept inaccessible to clients.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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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: 10/05/2023
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Report Continued from LIC 809...

SURROUNDING GROUNDS: The backyard has a covered outdoor area equipped with furniture for client use. . There is a completely fenced swimming pool, which is kept locked and inaccessible to clients..

BEDROOMS: There are three (3) double occupancy client bedrooms located on the second floor and were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is no staff room at the facility. There is 24-hour wake staff.

RESTROOMS: There are three (3) client restrooms are were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in all client bathrooms; the first bathroom measured at 105.8 degrees Fahrenheit at 10:14 a.m.; the second bathroom measured at 111 degrees Fahrenheit at 10:17 a.m.; and the third bathroom measured at 107.6 degrees Fahrenheit at 10:19 a.m.

RECORDS: Records review began at 10:38 a.m.; four (4) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, and consent forms. Four (4) out of four (4) client files did not have a copy of their Admissions Agreement and Medical assessment. Copies of Admissions Agreements and Medical Assessments were produced for all four (4) clients at the time of the visit. An advisory was provided.

Personnel records were reviewed for, but not limited to: personnel record (LIC 501), health assessments/screening (LIC 503), criminal record clearances (LIC 508), active first aid/CPR training, and the appropriate training. The facility did not have personnel records for any facility staff at the time of the visit. At 12:55 p.m., the Residential Supervisor called Human Resources (HR) via Microsoft Teams to request personnel records be sent to the facility for review. Personnel records were sent to facility and accessible to LPA later in the afternoon.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
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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: 10/05/2023
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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in the medication room on the first floor. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

INFECTION CONTROL: Upon entry, there is a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene and symptoms of communicable diseases. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.


DISASTER PREPAREDNESS: The last fire inspection was completed on 09/13/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 09/21/2023.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. The report was reviewed, and a copy of the appeal rights and report were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 10/05/2023 04:34 PM - It Cannot Be Edited


Created By: Martha Arroyo On 10/05/2023 at 03:06 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(c)(10)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 81065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above as the facility did not have a copy of the health screening report (LIC 503) for each facility staff member's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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HR emailed all personnel files to Compliance Specialist at the time of the inspection.

POC has been met.
Type B
Section Cited
CCR
81066(c)(11)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 81065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility did not have a copy of a negative Tuberculosis testing for each facility staff member's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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HR emailed all personnel files to Compliance Specialist at the time of the inspection.

POC has been met.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 10/05/2023 04:34 PM - It Cannot Be Edited


Created By: Martha Arroyo On 10/05/2023 at 03:06 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(c)(12)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 81019:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility did not have a record of the fingerprint clearance in each staff member's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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2
3
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HR emailed all personnel files to Compliance Specialist at the time of the inspection.

POC has been met.
Type B
Section Cited
CCR
81066(c)(12)(B)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 81019: (B) Documentation of either a criminal record clearance or exemption as required by Section 81019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility did not have an criminal record statement (LIC 508) on file for each staff member's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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HR emailed all personnel files to Compliance Specialist at the time of the inspection.

POC has been met.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 10/05/2023 04:34 PM - It Cannot Be Edited


Created By: Martha Arroyo On 10/05/2023 at 03:06 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(g)
Personnel Records
(g) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility did not have any personnel files at the facility at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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2
3
4
HR emailed all personnel files to Compliance Specialist at the time of the inspection.

POC has been met.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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