565850159-8-22-2023-29-AS-KDUK-CUXV39-20230822160423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850159
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:05:33 PM

Document Has Been Signed on 08/22/2023 04:05 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:	ERIKA ANDRADE		FACILITY TYPE:	772
ADDRESS:	11530 PRESILLA ROAD		TELEPHONE:	(805) 380-9041
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 6		CENSUS: 4	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Tiai Salanoa		TIME COMPLETED:	04:10 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 an unannounced Annual Inspection at the facility today. LPA arrived at 01:18PM and initially met with facility staff Arianna Esparza. Program Director Tiai Salanoa was contacted via telephone and arrived during facility tour. Entrance interview conducted. A tour of the physical plant was conducted with the facility staff at 01:23PM and the following observed: Fire extinguishers located throughout the facility were observed to be fully charged and last serviced on 07/07/2023. Smoke detectors and carbon monoxide detectors were tested at 03:50PM and were functional at the time of the visit. Sprinkler system was tested on 07/14/2023 and was functional at that time. 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 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 three (3) 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 were measured in client bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit. KITCHEN: Appliances and fixtures appeared clean and functional. The facility is utilizing an off-site kitchen for food preparation. LPA informed Program Director that a waiver is required in order to use an off-site Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 - PRESILLA	FACILITY NUMBER: 565850159
	VISIT DATE: 08/22/2023

NARRATIVE

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kitchen. Sufficient perishable and nonperishable food was observed. Cleaning supplies are stored in locked under-sink cabinets. Knives and other sharps were observed to be inside a locked office. There were no visible immediate hazards observed.

COMMON AREAS: These include the Family Room, Dining Room, Gym//Recreation 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 Family 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.

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, which was observed to be complete, is stored in the Medication Room. The Offices are kept inaccessible to clients unless properly supervised.

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 a safety net. Facility staff indicated clients use the pool on the weekends, when properly supervised. There were no visible immediate hazards or deficiencies.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The facility conducts monthly emergency disaster drills, with the most recent completed on 07/03/2023.

RECORD REVIEW: Beginning at 02:05PM, LPA reviewed staff and client files for but not limited to: client Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All four (4) client
Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: 08/22/2023

NARRATIVE

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files and staff records reviewed were in compliance with regulation at the time of the visit.

MEDICATION REVIEW: Beginning at 03:05PM, LPA reviewed medications for all four (4) clients. All medications reviewed were stored and documented per regulation.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and two (2) clients.

No deficiencies cited. Exit interview conducted with facility Program Director Tiai Salanoa. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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