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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850253
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:39:51 PM

Document Has Been Signed on 09/29/2022 02:39 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 - ALHAMBRAFACILITY NUMBER:
565850253
ADMINISTRATOR:HERNANDEZ, ALEXANDERFACILITY TYPE:
772
ADDRESS:2565 ALHAMBRA COURTTELEPHONE:
(714) 393-3523
CITY:SANTA ROSA VALLEYSTATE: CAZIP CODE:
93012
CAPACITY: 6CENSUS: 2DATE:
09/29/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Tiai Salanoa & Leopoldo VacaTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Post-Licensing Inspection at the facility today. LPA arrived at 10:39AM and met with facility Designee Leopoldo (Leo) Vaca. Entrance interview conducted.

A tour of the physical plant was conducted to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

COMMON AREAS: These include the Family Room and Dining Room. All furniture appeared clean and in good condition. A fireplace was observed in the family room to be adequately screened at the time of the visit. Fire extinguishers were observed throughout the common areas.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group/Family Room, Family Therapy Room, Medication Room, and two (2) offices located on the ground floor. There is also a Learning Lab located on the second story as well as one (1) additional office. Medications are stored in a locked first floor Medication Room. The medication room has adequate locked storage, as well as a locked refrigerator. Medications were observed to be properly labeled and medication records observed were documented per regulation. 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 were observed to be inside a locked closet in the locked laundry room.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate clients for (seven) 7 days and perishable food for two (2) days. Knives and other sharps are stored in a locked office, not in the kitchen. There were no visible immediate hazards observed.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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Document Has Been Signed on 09/29/2022 02:39 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/29/2022 at 01:30 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 - ALHAMBRA
FACILITY NUMBER: 565850253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 1out of 9 total staff working during the visit did not have their criminal record clearance transfered to this facility prior to employment which poses an immediate safety risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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LPA reviewed the staff's documents and was able to transfer Staff #1 (S1)'s fingerprint clearance to the facility. Facility Designee stated that the company's HR department handles all transfers and will review staff fingerprint associations to ensure all staff are appropriately associated to the facility.
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:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2022 02:39 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/29/2022 at 01:30 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 - ALHAMBRA
FACILITY NUMBER: 565850253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

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 2 out of 2 client files reviewed did not contain an admissions agreement which poses a potential personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Facility Designee was able to print and provide LPA a copy of the Admission Agreement for the new client just moving into the facility today. Designee will provide CCL a copy of remaining 2 clients Admission Agreements by the POC due date.
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:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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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 - ALHAMBRA
FACILITY NUMBER: 565850253
VISIT DATE: 09/29/2022
NARRATIVE
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BEDROOMS: There are three (3) Bedrooms, all of which are designated for shared client use. All bedrooms are located on the second story and were observed to contain appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

BATHROOMS: There are five (5) Bathrooms, two (2) on the ground floor and three (3) on the second floor. The bathrooms located on the ground floor include a full bath attached to the office designated for client use and a half bath in the main hallway for staff 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 paper and hygiene products.

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 an in-ground swimming pool, as well as a stable and barn, and open space. The pool is kept inaccessible to clients with the use of fencing that includes a locked gate. Staff have received the appropriate Water Safety Certification and Designee stated that qualified staff are present at all times that the pool is in use by clients. No immediate hazards were observed during the visit.

STAFF FILE REVIEW: LPA reviewed staff records during today's visit. All staff training records reviewed were in compliance with Title 22 regulation at the time of the visit. 1 (one) of 9 (nine) staff (Staff #1 - S1) working today has a criminal background clearance, but was observed to be not associated to the facility. Program Director indicated S1 has been employed at this location since June 2022.

CLIENT FILE REVIEW: LPA reviewed 2 (two) client file records during the visit. 2 of 2 client files reviewed did not contain an signed and dated Admission Agreement.

INFECTION CONTROL: During today’s visit, the LPA spoke with the facility Designee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. 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.

Pursuant to Title 22 Division 6 Chapter 2 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted with Facility Designee Leopoldo (Leo) Vaca and Program Director Tiai Salanoa. Today’s reports and appeal rights were reviewed and provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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