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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850157
Report Date: 10/15/2024
Date Signed: 10/15/2024 01:28:12 PM

Document Has Been Signed on 10/15/2024 01:28 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NEWPORT INSTITUTE - PIMLICOFACILITY NUMBER:
565850157
ADMINISTRATOR/
DIRECTOR:		STOKES, JEPFACILITY TYPE:
772
ADDRESS:10813 PIMLICO DRIVETELEPHONE:
(805) 523-2294
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 6CENSUS: 3DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Inguilber "Ingui" Alcantar - Residential Supervisor TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:20AM. LPA met with Residential Supervisor (RS) Inguilber “Ingui” Alcantar and reason for the visit was explained. Entrance interview conducted. HR Manager Karina Diaz and Residential Manager Leopoldo Vaca arrived at 11:02AM and Compliance Specialist Regan Mew arrived at 11:15AM during the inspection.

Beginning at 10:21AM, the LPA, along with RS Alcantar toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS (TREATMENT/THERAPY/OFFICE AREAS): At the time of the visit, treatment, therapy, and office furniture were observed to be in good condition. The LPA observed clients in common areas using computers at the time of the inspection. Group and individual activities are available. The facility maintained a comfortable temperature. LPA observed several fire extinguishers throughout the facility that were fully charged and last serviced 04/29/2024. LPA observed required postings throughout the common space. There is a separate laundry room, which is kept inaccessible to clients and contains locked detergents.

MEDICATIONS: Medications review began at 10:26AM; medications are centrally stored and locked in the medication room on the first floor. Medications are labeled and checked for expiration dates. Medications are documented and updated on a digital record used by facility staff. LPA observed the centrally stored medications and destruction record to be missing dates started. LPA observed the digital records and observed proper logging and documentation of the medications. LPA discussed with facility staff and explained that the centrally stored medications and destruction record shall be kept up to date alongside digital records.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157
VISIT DATE: 10/15/2024
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KITCHEN: LPA inspection in the kitchen/food service area at 10:40AM. 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 for expiration dates. Food items had clearly marked expiration and dates opened labels. Knives, sharps, cleaning supplies, and disinfectants are stored inaccessible in the locked Care Coordinator office.

SURROUNDING GROUNDS: The backyard has a covered outdoor area equipped with furniture for client use. LPA observed a 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. All client bedrooms 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.

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. One (1) upstairs bathroom is designated for staff use only. All bathrooms were supplied with appropriate soap and paper towels. At 10:57AM, water temperatures were measured in client bathrooms and measured within 106.1 degrees F – 114.7 degrees F, which is within the required range.

RECORD REVIEW: LPA began record review at 11:10AM. LPA reviewed three (3) out of three (3) client files for documents including, but not limited to: appraisals, medical records, admissions agreement, and consent forms. One (1) out of three (3) clients did not have a signed Admissions Agreement. Client reviewed and signed the Admission Agreement at the time of the visit. LPA reviewed three (3) personnel files for documents including, but not limited to: personnel record (LIC 501), health assessments/screening (LIC 503), criminal record clearances (LIC 508), active first aid/CPR training, and appropriate training. Personnel files were complete and had no missing documents.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEWPORT INSTITUTE - PIMLICO
FACILITY NUMBER: 565850157
VISIT DATE: 10/15/2024
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 10/02/2024. Smoke and carbon monoxide detectors and fire alarm systems are inspected by a third party vendor and were last inspected on 07/18/2024.

The following deficiency was 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 01:28 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/15/2024 at 01:13 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

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 in that one (1) out of three (3) clients did not have a signed admission agreement which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Client signed the admission agreement during the time of the visit. POC is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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