565850159-9-22-2021-29-AS-KDUK-C74U8D-20210922152121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850159
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:22:23 PM

Document Has Been Signed on 09/22/2021 03:22 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 - PRESILLA		FACILITY NUMBER:	565850159
ADMINISTRATOR:	STOKES, JEB		FACILITY TYPE:	772
ADDRESS:	11530 PRESILLA ROAD		TELEPHONE:	(714) 393-3523
CITY:	SANTA ROSA VALLEY	STATE: CA	ZIP CODE:	93012
CAPACITY: 6		CENSUS: 0	DATE:	09/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Crystal Goodwin & Jep Stokes		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kelly Dulek conducted a Pre-Licensing Inspection with Applicant Representative Crystal Goodwin and Administrator Jep Stokes. An Application to operate a Social Rehabilitation Facility (SRF) was received by Community Care Licensing (CCL) on 03/10/2021. A Fire Clearance was approved for a maximum capacity of six (6) ambulatory residents on 06/07/2021. The proposed physical plant is a two (2) story single family dwelling located in a residential neighborhood of Santa Rosa Valley, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate a maximum capacity of 6 Clients for (seven) 7 days. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Clients. Cleaning supplies will be stored in locked under-sink cabinets. Knives and other sharps will be stored in a locked cabinet. There were no visible immediate hazards observed. BEDROOMS: There are three (3) Bedrooms, all of which are designated for Resident 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 or discrepancies observed. BATHROOMS: There are six (6) Bathrooms, two (2) on the ground floor and four (4) on the second floor. The bathrooms located on the ground floor include a half bath in the main hallway for client use and a full bath attached to the office designated for staff use. The bathrooms located on the second floor are all full bathrooms and are three (3) designated for client use. 1 upstairs bathroom is designated for staff use only. All Bathrooms were supplied with appropriate paper and hygiene products. COVID-19 signs are required inside all bathrooms and were observed during the visit. Water temperatures were measured in Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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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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 - PRESILLA	FACILITY NUMBER: 565850159
	VISIT DATE: 09/22/2021

NARRATIVE

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(Continued from LIC 809)

all client bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit.

COMMON AREAS: These include the Family Room and Dining Room. Additionally, the attached 4-car garage will be used as a Gym/Recreation Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. There is a fireplace in the Family Room, which was observed to be adequately screened and Licensee Representative stated is disabled. There were no immediate hazards observed. A COVID-19 Screening & Hand Sanitizing Station was observed at the entrance to the facility. COVID-19 signs wer observed throughout the facility common areas.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group/Family Room, a Work Lab and an Office located on the ground floor. There is also a Family Therapy Room located on the second story, as well as an individual therapy office and 2 additional offices. Medications are stored in a locked second floor Medication Room. The medication room has adequate locked storage, as well as a locked refrigerator. The 1st Aid Kit is stored in the Medication Room. The Offices are kept inaccessible to clients unless properly supervised.

LAUNDRY: Locked Laundry Room is located on the ground floor. Laundry and cleaning supplies will be stored in locked cabinets inside the locked Laundry Room.

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, as well as safety net. The Applicant Representative and Administrator confirmed they are aware of the requirement of Water Safety Certification for staff providing supervision during pool use and that qualified staff must be present at all times that the pool is in use by clients. There were no visible immediate hazards or deficiencies.

COMPONENT II/COMPONENT III ORIENTATION: A Component II Orientation was completed telephonically
Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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

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 - PRESILLA	FACILITY NUMBER: 565850159
	VISIT DATE: 09/22/2021

NARRATIVE

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(Continued from LIC 809-C)

with the Licensee Representative and Administrator on 6/29/2021. A Component III Orientation was conducted with Licensee Representative on 3/16/2021 during a pre-licensing visit for Newport Academy-Alberca #565802317.

COVID-19 MITIGATION PLAN REPORT: During today’s visit, LPA reviewed the facility’s Plan for Epidemic Outbreak specific to COVID-19 Mitigation Plan Report.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the Licensing Report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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

LIC809 (FAS) - (06/04)

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