summary: Facility Evaluation

raw_content:
Narrative:
On 2-19-26, at 12:40pm, Licensing Program Analyst (LPA) Nancy O'Connell conducted a Case Management- Other inspection. The purpose of this inspection is to conduct a health and safety check and confirm the remediation of fire damage incurred during a previous natural fire disaster. LPA O'Connell was met by Monique Ambrester, Clinical Director (CD), Katie Pfeiffer, Executive Director for North Los Angeles Region, Lanhni Salanoa Facility Administrator (FA), and Paul Burnham, Facilities Director (FD). There are currently no clients in care. During the time of inspection, a walk-through was conducted of the entire physical plant. LPA viewed both interior and exterior portions of the facility. A walk-through of the interior portion of the physical plant (living room, kitchen, nursing station, family room, two staff offices (1st floor), three client bedrooms, and a classroom) reflected that the facility did not display any remaining particles or visible evidence of fire damage. Upon inspection of the exterior portion of the physical plant, LPA observed the property to be free of any debris/visible fire particles, and appeared to be in good physical repair. LPA observed a pool with a secure gate enclosure that meets regulatory requirements. LPA interviewed FD to inquire about efforts made to remediate fire/smoke damage and was informed that the facility was repaired initially through fire damage remediation to ensure that all smoke/soot particles were removed and cleaned. Once the facility completed remediation, then repairs and cleaning efforts (power-washing all surfaces, repainting, and replacing items as needed) were conducted to bring the facility into compliance. FD provided proof of formal fire remediation through documented reports from fire remediation companies. Additionally, the facility representatives provided documentation from Ventura County Fire Department (VCFD), indicating a visit was made on 02-10-22026, and the facility did not present with any visible effects from the fire, and is currently considered safe for occupancy. LPA O'Connell has confirmed that a new fire clearance is not required at this time. Based on California Code of Regulations, there are no deficiencies to be cited at this time. An exit interview was conducted and a copy of this report was provided to the Administrator via email.

met_with: Lahni Salanoa, Facility Administrator (FA)


state: CA

facility_name: NEWPORT ACADEMY-ARACENA

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 08/11/2023 at 9:05am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, Newport Academy Group Home, for the purpose of concluding the investigation on the above allegation: (3) Licensee does not ensure direct care staff training topics are appropriate for the client population at facility. The investigation included confidential interviews with facility and administrative staff. Per LPA request of training records, which the Licensee provided; a review of the records revealed that training topics are few and not varied, and do not meet the minimum, regulatory requirement. Based on all interviews conducted, and documents obtained, the Department has found the above allegations to be substantiated, meaning that, the preponderance of the evidence has been met. The facility is issued a citation. The following deficiency was cited [See page LIC9099-D for cited deficiencies]. An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to the licensee. The report will be emailed to Facility Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION GREATER LA AREA SC, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: NEWPORT ACADEMY-ARACENAFACILITY NUMBER: 565802318

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

report_type: Complaint Investigation

met_with: Sheryl Stone, HR Manager

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2022, at 1: PM Licensing Program Analysts (LPA's) Enrique Hernandez and Nancy O'Conell conducted an unannounced inspection, at the above-said facility, for the purpose of conducting a Post License Inspection. Licensing staff was met by Mydori Saipale Facility Administrator (FA), who granted access into the facility, who provided a tour of the entire facility, inside and out. General overview: This is a two-story home 3 bedroom, 6 bathrooms 4 therapy room, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. The staircase have access to the 2nd level of the home. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Medicines are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. LPA measured the water temperature and measured within safe temperature at 119 degrees Fahrenheit. First aid kits were checked and complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements for the Licensee's Foster Care License and Emergency Plan will be met. There are covered fireplaces in the home, and it was stated by Facility Administrator that they are not functional. A currently insured Toyota Sienna has the capacity to transport 6 clients and is equipped with a fully charged fire extinguisher. Seat belts were observed to be in good repair at the time of the inspection. Continued on LIC 809-C LPAs observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in the pantry. Chemicals and cleaning solutions are kept in locked. Breakfast area: consists of a table with 8 chairs, Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: is being utilized as a recreational area, equipped with a basketball hoop, pool tale, and plenty of locked cabinets for storage. Laundry area: equipped with a washer and dryer, and plenty of cabinet space where a fully charged fire extinguisher. School: equipped with a fully charged fire extinguisher, smoke alarm, 6 desk, 10 chairs, a printer, Applicant reported that each client shall have access to his/her own laptop during school hours. Bedroom #1 is occupied by two clients it has two twin size bed, adequate closet and drawer space, there is also .\an adjoining bathroom in good repair. Bedroom #2 is occupied by two clients it has two twin size bed, adequate closet and drawer space, there is also an adjoining bathroom in good repair. Bedroom #3 is occupied by one client; it has one full size bathroom in good repair. There is a metal plate with a portion of a cable sticking out near corner of the ceiling, closest to the window. LPA advised Administrator to remove plate/cable to ensure client safety. [See Confidential Names form (LIC811), dated 03/1/2022, for names]. ·Nursing station maintained a first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Nursing station along with supplies maintained in locked room. Continued on LIC C Group Therapy Rooms observed: · Individual Therapy Room: equipped with clean furniture in good repair. · Exercise Room: equipped with furniture, and which will be used for clients. · Individual & Family Therapy Room: equipped with 4 chairs, a small coffee table, and one locked closet The Exterior consists of the following: Jacuzzi in Ground: Located in the backyard, there is a fenced on the premises that meets regulations. The backyard also consists of the following: uncovered fireplace nonfunctional and a built-in BBQ island Due to time constraints, LPA shall return to complete the Post License Inspection. A copy of this report was discussed with the facility manager and will be email to the facility due to technical difficulties with the LPA's printer

report_type: Facility Evaluation

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2022, at 1: PM Licensing Program Analysts (LPA's) Enrique Hernandez and Nancy O'Conell conducted an unannounced inspection, at the above-said facility, for the purpose of conducting an Annual Required Inspection. Licensing staff was met by Mydori Saipale Facility Administrator (FA), who granted access into the facility, who provided a tour of the entire facility, inside and out. General overview: This is a two-story home 3 bedroom, 6 bathrooms 4 therapy room, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. The staircase have access to the 2nd level of the home. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Medicines are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. LPA measured the water temperature and measured within safe temperature at 119 degrees Fahrenheit. First aid kits were checked and complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements for the Licensee's Foster Care License and Emergency Plan will be met. There are covered fireplaces in the home, and it was stated by Facility Administrator that they are not functional. A currently insured Toyota Sienna has the capacity to transport 6 clients and is equipped with a fully charged fire extinguisher. Seat belts were observed to be in good repair at the time of the inspection. Continued on LIC 809-C LPAs observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in the pantry. Chemicals and cleaning solutions are kept in locked. Breakfast area: consists of a table with 8 chairs, Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: is being utilized as a recreational area, equipped with a basketball hoop, pool tale, and plenty of locked cabinets for storage. Laundry area: equipped with a washer and dryer, and plenty of cabinet space where a fully charged fire extinguisher. School: equipped with a fully charged fire extinguisher, smoke alarm, 6 desk, 10 chairs, a printer, Applicant reported that each client shall have access to his/her own laptop during school hours. Bedroom #1 is occupied by two clients it has two twin size bed, adequate closet and drawer space, there is also .\an adjoining bathroom in good repair. Bedroom #2 is occupied by two clients it has two twin size bed, adequate closet and drawer space, there is also an adjoining bathroom in good repair. Bedroom #3 is occupied by one client; it has one full size bathroom in good repair. There is a metal plate with a portion of a cable sticking out near corner of the ceiling, closest to the window. LPA advised Administrator to remove plate/cable to ensure client safety. [See Confidential Names form (LIC811), dated 03/1/2022, for names]. ·Nursing station maintained a first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Nursing station along with supplies maintained in locked room. Continued on LIC 809-C Group Therapy Rooms observed: · Individual Therapy Room: equipped with clean furniture in good repair. · Exercise Room: equipped with furniture, and which will be used for clients. · Individual & Family Therapy Room: equipped with 4 chairs, a small coffee table, and one locked closet The Exterior consists of the following: Jacuzzi in Ground: Located in the backyard, there is a fenced on the premises that meets regulations. The backyard also consists of the following: uncovered fireplace nonfunctional and a built-in BBQ island Due to time constraints, LPA shall return to complete the Annual Required Inspection. A copy of this report was discussed with the facility manager and will be email to the facility due to technical difficulties with the LPA's printer

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023, at 11:15am Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection, at the above-listed facility, for the purpose of conducting an Annual Required Inspection. Licensing staff was met by Mydori Saipale Residential Program Manager, who granted access into the facility, and provided a tour of the entire facility, inside and out. General overview: This facility is a two-story home, with 3 bedroom, 6 bathrooms, therapy rooms, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. The staircase provides access to the 2nd level of the home. There are no security bars on the windows, but staff maintain oversight of the window cranks to ensure supervision. There are no firearms or dangerous weapons in the home, and client do not have access to knives, or cleaning supplies. Medicines are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. LPA measured the water temperature and measured within safe temperature. The facility maintains appropriate signage posted in the facility. There are covered fireplaces in the home, and they are not functional. The facility has a insured and registered vehicle for use which has the capacity to transport 6 clients and is equipped with first aid kits. The brake lights, headlights, windshield wipers, and seatbelt was observed to be functional. Continued on LIC809C LPA observed the following during inspection: Living Room: with a securely covered fireplace, tv, seating for all residents, and access to the backyard. Dining Room: equipped with a large table with seating for all residents. Kitchen: equipped with a refrigerator, cooktop - gas, double oven, microwave, breakfast nook, kitchen island has a sink located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in the pantry. Chemicals and cleaning solutions are kept in locked underneath sink Breakfast area: consists of a table with chairs, Family Room: equipped with a secure cover on the fireplace(purposely non-functional), and plenty of clean furniture in good repair. Garage: is being utilized as a laundry area and recreational area. This space is equipped with a washer/dryer, gym equipment, a basketball hoop, pool table, and plenty of locked cabinets for storage. There is plenty of cabinet space and a fully charged fire extinguisher. School: equipped with a fully charged fire extinguisher, smoke alarm, 6 desks, 6chairs, 6 computers, a printer and a station for the teacher. Bedroom #1 is occupied by two clients and has two twin size beds, adequate closet space, and one desk. There is also an adjoining bathroom in good repair. Bedroom #2 is occupied by two clients and has two twin size bed, adequate closet space and one desk. There is also an adjoining bathroom in good repair. Bedroom #3 is occupied by one client; it has one full size bathroom in good repair. ·Nursing station centrally stored medication logbook, medications, a first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration if needed. Nursing station along with supplies maintained in locked room. LPA reviewed medication logbook and medication to confirm accuracy of administration and documentation. Continued on LIC809C Group Therapy Rooms observed: · Individual Therapy Room: equipped with clean furniture in good repair. · Individual & Family Therapy Room: equipped with 4 chairs, a small coffee table, and one locked closet The Exterior consists of the following: Jacuzzi in Ground: Located in the backyard, surrounded by a 5ft. fence. LPA observed staff test the net covering and observed the netting to be secured, in good repair and able to prevent access to jacuzzi water. Safety features meets regulation. The backyard also consists of the following: uncovered fireplace nonfunctional and a built-in BBQ island LPA and RPM conducted a walk of the entire perimeter of the property and LPA observed property to be clean, secured and free of obstructions. Based on Title 22, and California Code of Regulations, there are no deficiencies to be cited at this time. Due to time constraints, LPA shall return to complete the file review and staff/client interviews for this Annual Inspection. A copy of this report was discussed with the facility manager and a copy was provided.

met_with: Mydori Saipale, Residential Program Manager (RPM) and Tone Reyes, Residential Program Director (RPD)


summary: Facility Evaluation

raw_content:
Narrative:
On October 23, 2023 at 10:30am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility and was met by Residential Supervisor (RS). The purpose of the visit was to conduct a collateral interview, in regards to a complaint at another licensed facility. LPA Wilson conducted confidential interviews with (FT) [See LIC811 dated 10/23/2023 for a list of confidential names.] There are no deficiencies to be cited at this time. A copy of this report was left at the facility.

met_with: Residential Supervisor (RS)


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 25, 2025, at 09:30am Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection, at the above-listed facility, for the purpose of conducting an Annual Random Inspection. Licensing staff was met by Lahni Salanoa, Residential Supervisor(RS) ,and Regan Mew, Compliance Specialist, who granted access into the facility, and provided a tour of the entire facility, inside and out. There were no clients in care during the time of inspection. During the inspection, additional staff joined: Karina Diaz, HR Manager (HRM), Elayna Bray, Director of Operations (DO), and Katie Pfeiffer, Executive Director (ED). Upon entrance to the facility, LPA observed a car in the driveway and inquired about ownership. RS communicated that the car belonged to a staff that was working with the adult clients in the facility. Upon further interview, LPA was informed that adult clients were transitioned to this facility from another one of Newport Academy's adult facilities. RS informed LPA that the adult clients were in the home from 2/21/25- 2/25/25. LPA inquired about information with CS and received confirmation that the facility was temporarily housing adult clients from one of their Adult-Rehabilitation facilities. LPA informed RS and CS that this facility was not allowed to be utilized beyond the capacity of the license, and a deficiency would be cited today. RS and CS agreed. General overview: This facility is a two-story home, with 3 bedroom, and 6 bathrooms. The facility has 2 therapy rooms, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a front/backyard. There are no facility cameras on the premises. The staircase provides access to the 2nd level of the home where there are three bedrooms, a classroom and a supply closet. There are no security bars on the windows. There are no firearms or dangerous weapons in the home, and client do not have access to knives, or cleaning supplies. Medicines are kept in the downstairs nursing office, behind two locked doors and one locked medicine cabinet. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. The facility maintains appropriate signage posted in the facility including the license, LIC610 (updated during time of inspection), client rights and Community Care Licensing Division reporting hotline. There are covered fireplaces in the home, and they are not functional. The facility has two insured and registered vehicles for use which has the capacity to transport 6 clients each. LPA confirmed current registration, insurance, and operation status of the vehicles during inspection. Continued on LIC809C Group Therapy Rooms observed: · Individual Therapy Room: one is located within the garage, and one is located in the hallway adjacent to the kitchen and has an adjoining bathroom. Both rooms are equipped with clean furniture in good repair. · Individual & Family Therapy Room: equipped with 4 chairs, a small coffee table, and one locked closet The Exterior consists of the following: Jacuzzi in Ground: Located in the backyard, surrounded by a 5ft. fence found to be in good working condition. The backyard also consists of the following: uncovered fireplace nonfunctional and a built-in BBQ island that is currently not in use.LPA observed property to be clean, secured and free of obstructions. Based on Title 22, and California Code of Regulations, there is one deficiency to be cited at this time.See LIC809D for details. A copy of this report was discussed with the Compliance Specialist and a copy was provided. LPA observed the following during inspection: Living Room: with a securely covered fireplace,tv, seating for 6 residents, and access to the backyard. Dining Room: equipped with a large table with seating for 6 residents. Kitchen: equipped with a refrigerator, cooktop - gas, double oven, microwave, breakfast nook, kitchen island has a sink located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in the pantry and locked in a tool box. Chemicals and cleaning solutions are kept in locked underneath sink Breakfast area: consists of a table with chairs with enough seating for 6 clients Family Room: equipped with a secure cover on the fireplace(purposely non-functional), and plenty of clean furniture in good repair. Garage: is being utilized as a recreational area, with multiple items available for games/sports/recreation (gym equipment, a basketball hoop, pool table, and plenty of locked cabinets for storage. There is plenty of cabinet space and a fully charged fire extinguisher). Hallway adjacent to the garage: This space is equipped with a washer/dryer, office for staff, and locked cabinets for supplies. School: located on the second floor, and equipped with a fully charged fire extinguisher, smoke alarm, 6 desks, 6 chairs, 6 computers, a printer and a station for the teacher. Bedroom #1 maintains two twin size beds, adequate closet space, and one desk. There is also an adjoining bathroom in good repair. Bedroom #2 is occupied by two clients and has two twin size bed, adequate closet space and one desk. There is also an adjoining bathroom in good repair. Bedroom #3 maintains two beds, one full size bathroom in good repair, and connects to the classroom. ·Nursing station: located on the first floor near the family therapist office, and maintains centrally stored medication logbook, medications that will be used for clients, a first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration if needed. At 11:15am, LPA observed two non-prescribed medications located within the nursing office. One medication was identified as Narcan, and the second medication was identified as Epinephren (epi-pen). LPA inquired about use of medications, and CS communicated that the facility maintains these medications on site for all facilities as emergency precautions. LPA confirmed that medications are not prescribed to specific individuals. Upon further review, the DO communicated that the medications are prescribed to the facility by Newport Academy's Medical Director, Samantha Figueroa, Nurse Practitioner. Continued on LIC809C

Deficiencies:
80010(a): Deficient Practice Statement
1
2
3
4Based on interview, the licensee did not comply with the section cited above by ations specified on the license, including the capacity limitation.

met_with: Lahni Salanoa, House Manager

title:
Limitations on Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On 9/3/25 9:30AM Licensing Program Analyst (LPA) Nancy O'Connell, and LPA Wendely Moodie-Naranjo made an unannounced visit to the above-listed facility for the purpose of conducting a Case Management - Annual Continuation inspection. LPA was met by Karina Diaz, Human Resources Manager. LPA was informed that there are no clients in care at this time. Staff provided a facility gate code which is saved in Department records. LPA met with S1 and informed her that the purpose of the visit is to conduct and complete the Annual inspection. LPA inquired about the current census, requested the staff roster. LPA requested to interview selected staff and staff files and was informed that S2's staff file was not readily available but would be requested. LPA informed S1 that all personnel files for staff working in facilities and with children would need to be made accessible. S1 was able to obtain access of S2's record from another staff member. See Confidential names list dated for 9/3/25, for names. Staff Interviews: LPA conducted a confidential interviews with two staff, FA and S File reviews: LPA conducted 2 file reviews of FA and S2. During the time of inspection, LPA completed the related Care Tool and addressed the following sections: Emergency Intervention, and Staff records. Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulation, there are no deficiencies cited during this inspection. An exit interview was conducted and S1 was informed that the Annual Inspection was completed. A copy of this report was sent to the administrator via email.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 07/09/2021 at 9:00am, Licensing Program Analyst (LPA) Enrique Hernandez conducted a Case Management - Incident inspection at Newport Academy Arecena, and met with the Facility Administrator, in response a Special Incident Report that was submitted to Community Care Licensing (CCL), in order to investigate a possible violation. The incident, which occurred on 06/16/2021, involved client (C1), who obtained a box cutter and used it to self-injure on Monday 06/14/2021 and on 06/15/2021 while C1 was in the shower. When the residential supervisor (S1) asked C1, where did they get the box cutter? C1 stated that it was in the while staff were finishing putting up a basketball hoop on 6/14/2021. [See the LIC811 (LIC811) Confidential Name List form, dated 07/09/2021, for names] LPA Hernandez interviewed the facility Administrator (FA), who confirmed that the client (C1) was able to obtain the boxcutter when the Care coordinator (S2) was setting up a basketball hoop and turned his back on C1. Per California Code of Regulations, Title Regulations, Division 6, Chapters 1 & 5, the following deficiencies have been cited. (See LIC809-D) Exit Interview conducted, and a copy of this report was left at the facility.

met_with: Mydori Saipale


summary: Facility Evaluation

raw_content:
Narrative:
On August 11, 2023 at 9:05am, Licensing Program Analyst (LPA) Christine Wilson met with the above facility, to conduct a case management deficiency. During the complaint investigation control ID# 31-CR-20230509115043 it was revealed that the licensee does not document training hours for each training. The following deficiencies were identified and the facility is issued a citation [See page LIC809-D for cited deficiencies]. An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to the licensee. This report will be emailed to Facility Administrator.

met_with: Sheryl Stone, HR Manager)


facility_name: NEWPORT ACADEMY-AUTUMN

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced PreLicensing inspection on 3/17/2022 and met with Michelle Good, Residential Director who assisted with the inspection. LPA toured the inside and outside of the facility during the inspection. LPA observed that the house is clean and safe for potential residents and the facility is ready to accept clients at this time. LPA observed that the house has three dual occupancy rooms for clients, three therapy rooms, and one classroom in the facility. LPA observed that there are five bathrooms in the facility. All of the bathrooms in the facility have operational showers but only three of the showers will be utilized by clients in care but all toilets and sinks will be accessible and available for clients to use. LPA toured the kitchen and did observe that it is fully stocked with kitchen supplies and cooking utensils but there was no food in the facility for clients. LPA advised that there has to be food in the facility prior to accepting clients. LPA requested receipts be sent to LPA for the purchase of food prior to accepting clients. In touring the facility grounds, LPA observed that there is a separate administration building where all of the administrative staff will be working on site. LPA observed that there is no lock on the gate separating the administrative house from the main facility. LPA instructed the facility that there has to be lock on this gate prior to accepting clients as there is a koi pond on the administrative side of the property. LPA observed that the administrative side of the property is not for use of the clients and no clients shall be inside of that building. LPA did discuss potential of using the administrative side of the property for growing and horticulture activities for the clients in care but that the koi pond needs to be covered or otherwise made in accessible to clients that would be on the administrative side of the facility for those purposes. LPA observed that there are 6 fire extinguishers in the facility and they are all tagged with an inspection date of 2/14/2022. LPA observed that there are ten fire pull stations in the facility. LPA did advise that the facility place screens on some of the windows that could be opened for air circulation purposes. Some of the windows were in other areas of the facility. None of the client bedroom windows lacked screens. LPA observed that the outdoor activity space includes a tennis court and there are activities in the two car garage as well that included ping pong, fooseball table, weights, and other exercise bikes accessible to clients. LPA did advise that the facility make inaccessible cabinets and other areas that they do not wish clients to have access to. There is a separate one car garage on the property that appears to have a few items for storage in this garage. LPA was advised that this garage will be inaccessible to clients. LPA observed that the water temperature measured 117.5 degrees Fahrenheit during the visit in the main bathroom where clients have access. LPA observed that the facility is fully furnished and ready for the clients and LPA advised that the facility shall be notified of the official licensure date upon approval by Licensing Program Manager review. LPA did provide the facility with technical advisory notices for the koi pond and the air conditioning unit during the inspection today. Exit interview conducted and document was provide to Ms. Good.

visit_type: Prelicensing

met_with: Michelle Good, Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced post licensing inspection to the facility on 6/21/22 at 12: PM and met with Breana Bertolino, Administrator who assisted with the inspection. LPA toured the facility inside and out and observed that the facility to be in substantial compliance. LPA observed that there is water in all of the bathrooms and that client rooms had the required furniture and bedding as required. LPA interviewed all five clients in the facility and two staff while in the facility. LPA reviewed client records while at the facility but did not have adequate time to review staff records. LPA observed that the smoke detectors and carbon monoxide detectors were functioning as required. LPA observed that the fire extinguishers throughout the facility were last inspected on 2/14/22. LPA observed that the facility has a classroom for clients to do their schooling and an exercise area for indoor exercising. LPA observed that the facility has a tennis court for the youth and they indicated that they do use it regularly. LPA observed that there is outdoor seating appropriate and adequate for all of the clients. LPA observed that there are several therapy rooms throughout the facility. While in the facility, LPA observed youth to be interacting with staff and engaged with staff. LPA did cite the facility for 84068.2(b) Needs and Services Plans as the facility does not complete these plans for youth placed in the facility. Exit interview was conducted and document was provided with appeal rights.

met_with: Breana Bertolino, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management visit on 7/6/22 at 11: AM and met with Bre Bertolino, Administrator. LPA made the visit to discuss the following observed policies: * Drug testing is being conducted twice weekly on all the youth in the program * Youth are "wanded" when returning from outings which means that the staff use a metal detecting wand to search the youth as they return to the facility from outings. * Needs and Services Plans continue to be an issue that needs to be addressed as the agency is not doing them for the youth in their care and are instead doing Treatment Plans * Allowances are not being given to the youth in care LPA discussed all of these issues while at the facility and did inform Ms. Bertolino that the Department will be scheduling a conference with Newport and the Department's management to discuss these issues and go over the final review of the Program Statement. Exit interview was conducted and document was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 1/18/23 at 2: PM and met with Breana Bertolino, Administrator to discuss an incident report. The incident report, is dated 12/21/22 in which a client ingested hand soap and was taken to the emergency room. LPA discussed what the facility is doing to ensure the safety of this client in the facility. LPA questioned how the facility is ensuring the safety of the youth and was informed that the facility now monitors youth closely and removes items for the safety of the client including hand soap and hand sanitizer. Administrator states that when clients that have a propensity of ingesting items then staff stands outside and administers the soap to the client when they finish using the restroom. LPA obtained a copy of client's treatment plan. LPA asked staff about the types of products used in the facility and was informed that the soap is a non-toxic soap used but that it was decided to take client to the emergency room due to the volume ingested. Client is still in the program and staff are working to mitigate further issues of the same nature. No citations were issued on this date and exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Monica Roberts made an unannounced annual inspection to the facility on 2/21/23 at 11: AM and met with Breana Bertolino, Administrator. LPAs toured the facility inside and out and observed that the facility was clean and sanitary. LPAs observed that the facility had multiple fire extinguishers throughout the facility that were last serviced on 2/17/23. LPAs observed that the water temperature throughout the facility measured 112 degrees Fahrenheit. LPAs observed that the smoke detectors were functioning as required and that the facility had at least one operable carbon monoxide detector. LPAs observed that there was adequate food - perishable and non perishable - for the clients that are in care. LPAs observed that there is a food service where client meals are brought to this location from a sister facility. LPAs observed that the food is delivered in a storage box that holds the temperature during transport. LPAs observed that the facility has two dual occupancy client rooms and two single occupancy client rooms at the facility. All rooms were observed to meet the storage requirements and space as required. LPAs observed that there are five bathrooms accessible to clients and all had hot water, flushing toilets and paper products as necessary. LPAs observed some issues during the inspection and did give the facility four technical advisories including for not having tweezers in the first aid kit, use of common towels in the bathroom (clients admitted to leaving bathing towels in the bathroom due to not having a hanger in their bedrooms), the disaster plan does not have instructions on how to turn off utilities, and not having a monthly log of restraints. Due to technical difficulties, the inspection concluded at 1: PM and had to resume on a continuation inspection. End of documentation.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Monica Roberts continued an unannounced annual inspection to the facility on 2/21/23 at 2: PM and met with Breana Bertolino, Administrator. LPA Hill had technical difficulties during the inspection and had to continue the inspection utilizing this document. LPAs interviewed clients and staff during this inspection and reviewed medications during the inspection. LPA Hill asked nursing staff about parent/guardian authorization for psychotropic medication, nursing staff stated that she did not think that there was authorization. LPA Hill observed melatonin and nursing staff stated that they have to obtain written approval for melatonin prior to administering to clients. LPA Hill cited the facility for Title Group Home Regulation, 84070(b)(12) Children's Records. LPAs observed that the facility is administering psychotropic medication without written authorization from the parent/guardian. This regulation states that the facility is required to obtain and maintain written authorization for each psychotropic medication as required. Additional inspection is required and LPAs did advise the facility that there is need for an additional inspection date. End of documentation.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/28/26, Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility and met with Operations Manager (OM) Fausto Aramburo. The purpose of the visit was to conduct a Required Annual Inspection of the facility. The last Annual Inspection for the facility was on 02/21/23. LPA utilized the CARE Tool to complete the Annual Inspection. The facility is licensed to provide treatment services for ambulatory children ages 12 to 17 years. The facility currently has no (0) clients. The facility is licensed for a maximum capacity of six (6). Staff to client ratio is 2:6. Currently the facility has no clients placed, and no staff working; facility has not had clients since 06/28/24. The facility is considering closing and will contact the department if and when they do. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility had no noticeable odor. There is a total of five (5) bedrooms; three (3) available for clients, with two (2) clients to a bedroom and two (2) are used for offices. LPA observed the client bedrooms, living rooms, kitchen, four (4) bathrooms, the backyard, the garage, and the staff office to be clean, empty with no furniture due to not being ready to accept clients. LPA observed each client bedroom to have a closet. Smoke alarms were in working order. The facility has no outstanding fees. LPA did not review any client files due to none at the moment and LPA did not review any staff files due to none at the moment. LPA did not review Administrator's qualification due to none at the moment. LPA interviewed zero (0) staff and LPA interviewed zero (0) clients. No citations were given on this date. A signed copy of this LIC-809 and LIC-809C report was provided to Operations Manager (OM). An exit interview was conducted.

met_with: Operations Manager (OM) Fausto Aramburo


facility_name: NEWPORT ACADEMY-AVOCADO

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 7/21/23, at 11:30am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the finding. LPA spoke with Mydori Saipale and together, discussed the investigative finding. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, relevant parties have been accounted for.Supporting evidence includes: interviews with house residents and staff which do not corroborate the observance or experience of any of the allegations. Further, during an initial onsite inspection conducted by LPA O'Connell, knives were observed to be secure, and safeguarded from client access. LPA did not receive any evidence to support the validity of the identified allegations and there were no statements obtained to verify with certainty that the allegations occurred. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Staff #1

complaint_status: unsubstantiated


raw_content:
Narrative:
(Continuation of Findings Pg 2) Based on all interviews conducted, and documents obtained, the Department has found the above allegations to be unsubstantiated, meaning that, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies to be cited at this time.

Investigation Findings:
13On 08/11/2023 at 9:05am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, Newport Academy Group Home, for the purpose of concluding the investigation on the above allegations: (1) Licensee does not ensure direct care staff obtain the minimum number of initial training hours required. (2) Licensee does not ensure direct care staff obtain the minimum number of annual training hours required. Although the Human Resources Administration provided training records to LPA Wilson, these records do not document the number of hours completed for each staff and for each training course; therefore, there is no way of determining whether a staff has met the minimum number of training hours for any completed training course. (Continued Findings on 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION GREATER LA AREA SC, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: NEWPORT ACADEMY-AVOCADOFACILITY NUMBER: VISIT DATE: 08/11/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Narrative:
Confidential interviews were conducted with facility staff and collateral contacts. During a confidential interview S1 denied sexually abusing any client and denied entering a client's room without additional staff present. During confidential interviews with facility staff, it was indicated that no other staff witnessed any type of sexual abuse or inappropriate actions by S1. The alleged victim C1 was interviewed by Ventura County Sheriff and the report documenting the interview was reviewed by Investigator Laura Garcia. It was revealed that there was insufficient evidence regarding the criminal investigation into sexual abuse and that the District Attorney's Office officially rejected the case due to lack of evidence. It was reported that S1 submitted S1's electronic devices to Ventura County Detectives and that nothing was discovered on S1's devices to corroborate the allegation. Based on the statements and documents obtained, the allegation is determined to be unsubstantiated as the evidence obtained was not sufficient to substantiate the allegation. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited at this time. Exit interview completed. A copy of this report was emailed to Facility Administrator.

Investigation Findings:
13On 10/22/2025, at 11: AM, Licensing Program Analyst (LPA), Andrew Upshaw conducted a subsequent complaint inspection to deliver findings concerning the above-mentioned allegation. LPA Upshaw met with Lahni Salanoa, Administrator, to discuss the investigative outcome. On 04/09/2025, Community Care Licensing Division (CCLD) received a complaint alleging that Staff therapist (S1) sexually abused a minor client (C1). The allegation was referred to CCLD Investigations Branch, and the investigation was conducted by Investigator Laura Garcia. (Continued on page 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Andrew Upshaw LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: NEWPORT ACADEMY-AVOCADOFACILITY NUMBER: VISIT DATE: 10/22/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Lahni Salanoa, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2021 at 9:05 am Licensing Program Analyst (LPA's) Enrique Hernandez and Daphne Edison made an unannounced visit for the purpose of conducting a case management incident regarding the reporting requirements. LPA's met with Executive Director Jep Stokes and the facility administrator Mydori Saipale who granted access into the facility Newport Academy-Avocado and together discussed the Case Management details to address concerns regarding reporting requirements. The department received two incident reports on 9/14/2021. The first incident occurred on 6/30/2021, the second incident occurred on 8/6/2021. After further investigation and documentation received from the facility administrator, the reports were sent in adherence to reporting incidents on time. [See Confidential Names form (LIC811), dated 010/07/2021.] PER California Code Regulation, TITLE 22, DIVISION 5, CHAPTERS 1, General Licensing Regulations, no deficiencies cited at this time. Exit interview was conducted with the facility Administrator. A copy of this report was left with the facility administrator whose signature on this form confirm receipt of this document.

met_with: Jep Stokes


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2021 at 9:05 am Licensing Program Analyst (LPA's) Enrique Hernandez and Daphne Edison made an unannounced visit for the purpose of conducting a case management Post Licensing inspection. LPA's met with Executive Director Jep Stokes and the facility administrator Mydori Saipale who granted access into the facility Newport Academy-Avocado During the visit LPA's were informed by the facility nurse Denise Gutierrez that they were waiting for two other clients test results for COVID During today's inspection, LPA's were unable to complete the physical inspection due to possible positive COVID youth in the home. LPA's conducted operations and disaster preparedness Sections [See Confidential Names form (LIC811), dated 010/07/2021.] Due to time constraints, LPA's shall return to complete the Post license Inspection LPA will return to conduct a physical plan, review personnel and clients files to ensure it meets regulatory requirements. Client and staff interviews will be conducted at a later date. PER California Code Regulation, TITLE 22, DIVISION 5, CHAPTERS 1, General Licensing Regulations, no deficiencies cited at this time. Advisory notes were issued. Exit interview was conducted with the facility Administrator. A copy of this report was left with the facility administrator whose signature on this form confirm receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2022, at 9: AM Licensing Program Analysts (LPA's) Enrique Hernandez and Nancy O'Connell conducted an unannounced inspection, at the above-said facility, for the purpose of conducting an Post License Inspection. Licensing staff was met by Mydori Saipale Facility Administrator (FA) and Tone Reyes the Director who granted access into the facility, who provided a tour of the entire facility, inside and out. This is a one-story home 3 bedroom, 8 bathroom, 3 therapy room, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Medicines are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. During the inspection LPA measured the water temperature and measured within safe temperature at 119 degrees Fahrenheit. First aid kits were checked and complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements for the Licensee's Foster Care License and Emergency Plan will be met, aside from the Group Home License. There are covered fireplaces in the house and the Director stated that they are not working. Currently the facility has two insured Toyota Siennas capacity to transport 6 clients and is equipped with a fully charged fire extinguisher. Seat belts were observed to be in good repair at the time of the inspection. Continue On LIC 809-C LPAs observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in a locked drawer space within one of the lower kitchen cabinets. Chemicals and cleaning solutions are kept in locked. Breakfast area: consists of a table with 8 chairs, Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: locked, finished, 4 garage spaces, equipped with a basketball hoop, pool tale, and plenty of locked cabinets for storage. Facility administrator stated that they are using it as storage and clients are not allowed in there. Laundry area: equipped with a washer and dryer, and plenty of cabinet space cleaning supplies were locked and a fully charged fire extinguisher. School: equipped with a fully charged fire extinguisher, smoke alarm, 6 desk, 10 chairs, a printer, it was stated by the facility administrator that each client shall have access to his/her own laptop during school hours. 3 bedrooms observed to each have its own bathroom, with sufficient lighting, drawer and closet space, comfortable two twin mattresses, and clean lines, blankets, and pillows. Nursing station, Located in the master bedroom equipped with, 3 desk in a table There is a bathroom with two sinks and walking closet first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Group Therapy Rooms observed: · Office Therapy Room: equipped with clean furniture in good repair. · Second Therapy Room: equipped with furniture in good repair. The Exterior consists of the following: Pool: Located in the backyard, there is a fencing on the premises that meets regulations. Also, a net was covering the pool, Continue on LIC809-C Due to time constraints, LPA shall return to complete the Post License Inspection by conducting the file review for Six clients (C1, C2, C3, C4,C5 and C6). A copy of this report was discussed with the facility administrator and will be email to the facility due to technical difficulties with the LPA's printer


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2022, at 9: AM Licensing Program Analysts (LPA's) Enrique Hernandez and Nancy O'Connell conducted an unannounced inspection, at the above-said facility, for the purpose of conducting an Annual /Required Inspection. Licensing staff was met by Mydori Saipale Facility Administrator (FA) and Tone Reyes the Director who granted access into the facility, who provided a tour of the entire facility, inside and out. This is a one-story home 3 bedroom, 8 bathroom, 3 therapy room, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Medicines are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. During the inspection LPA measured the water temperature and measured within safe temperature at 119 degrees Fahrenheit. First aid kits were checked and complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements for the Licensee's Foster Care License and Emergency Plan will be met, aside from the Group Home License. There are covered fireplaces in the house and the Director stated that they are not working. Currently the facility has two insured Toyota Siennas capacity to transport 6 clients and is equipped with a fully charged fire extinguisher. Seat belts were observed to be in good repair at the time of the inspection. Continue On LIC 809-C LPAs observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects are stored in a locked drawer space within one of the lower kitchen cabinets. Chemicals and cleaning solutions are kept in locked. Breakfast area: consists of a table with 8 chairs, Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: locked, finished, 4 garage spaces, equipped with a basketball hoop, pool tale, and plenty of locked cabinets for storage. Facility administrator stated that they are using it as storage and clients are not allowed in there. Laundry area: equipped with a washer and dryer, and plenty of cabinet space cleaning supplies were locked and a fully charged fire extinguisher. School: equipped with a fully charged fire extinguisher, smoke alarm, 6 desk, 10 chairs, a printer, it was stated by the facility administrator that each client shall have access to his/her own laptop during school hours. 3 bedrooms observed to each have its own bathroom, with sufficient lighting, drawer and closet space, comfortable two twin mattresses, and clean lines, blankets, and pillows. Nursing station, Located in the master bedroom equipped with, 3 desk in a table There is a bathroom with two sinks and walking closet first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Group Therapy Rooms observed: · Office Therapy Room: equipped with clean furniture in good repair. · Second Therapy Room: equipped with furniture in good repair. The Exterior consists of the following: Pool: Located in the backyard, there is a fencing on the premises that meets regulations. Also, a net was covering the pool, Continue on LIC809-C Due to time constraints, LPA shall return to complete the Annual/Required Inspection by conducting the file review for Six clients (C1, C2, C3, C4,C5 and C6). A copy of this report was discussed with the facility administrator and will be email to the facility due to technical difficulties with the LPA's printer

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2024, Licensing Program Analyst Connie Jones-Steward conducted an annual random inspection of the facility. The inspection began at 9: AM. Compliance Specialist Regan Mew and Residential Supervisor Andrew Westfall assisted with the inspection . The following was observed. This is a one-story home with 3 bedrooms, 7 bathrooms, 3 therapy rooms, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. Although the floor plan shows 8 bathrooms, one was converted to a pantry. Per Ms. Mew, the conversion was done prior to licensure. There are currently 6 female clients who are placed by their parents. There are no security bars on windows. The pool and jacuzzi are enclosed behind a mesh gate that is key locked. There is also a pool cover. There are smoke detectors and carbon monoxide detectors in the hallway between bedrooms. LPA observed several fully charged fire extinguishers. There are 2 fireplaces which are securely gated. Kitchen and bathroom areas are well maintained. Food supply meets Title 22 requirements. Hot water temperature is within a safe range. All medications, knives and household cleaners are safely stored in locked areas. There is a complete supply of first aid items. All bedrooms have two twin bed beds with the required linens in good condition. Each room has the required drawer and closet space. The facility van was checked for working safety equipment. There is a first aid kit and maintenance log kept in the van. The log is filled in after every trip. The facility was cited under Title 22 80087(e)(1) for Buildings and Grounds. LPA reviewed client records including medication logs. A follow-up inspection will be conducted to inspect staff records and to interview staff and clients,

met_with: Regan Mew, Compliance Specialist


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Lead Care Coordinator Romona Acosta to deliver the notice that previous deficiencies cited against this location and the Alberca were dismissed upon appeal

met_with: Romona Acosta, Lead Care Coordinator


raw_content:
Investigation Findings:
13On 11/24/2025, at 11:45 am, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with Behavioral Health Specialist (S1), Ramona Acosta, and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nestor Gomez, all relevant parties have been accounted for. The validity of the allegations could not be determined. The parties interviewed either confirmed or denied the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nestor Gomez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Ramona Acosta - Behavioral Health Specialist


summary: Facility Evaluation

raw_content:
Narrative:
On 05/4/2021, at Licensing Program Analyst (LPA) Enrique Hernandez conducted a Case Management - Incident inspection at Newport Academy- Avocado and met with the administrator in response to a Special Incident Reports, submitted to Community Care Licensing (CCL), LPA and Administrator together discussed incident reports dated 04/22/2021, 04/29/2021 of the medication errors. LPA informed administrator that the incidents occurred on two different occasions, with two different clients and two different employees. The administrator said there was a training on how to administer the medication correctly on 4/27/2021 so she was not happy it happened again on 4/29/2021 that staff misread dosage on the label and give the client the wrong amount. The administrator stated that they will have another training online today 5/4/ PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations, The following deficiency is cited due to medication errors. (See 809-D) Exit interview was conducted and Appeal Rights were issued and a copy of this report will be emailed to the Licensee, in order to obtain a signature. Signature will be on file.


summary: Facility Evaluation

raw_content:
Narrative:
On August 11, 2023 at 9:05am, Licensing Program Analyst (LPA) Christine Wilson met with the above facility, to conduct a case management deficiency. During the complaint investigation control ID# 31-CR-20230509115043 it was revealed that the licensee does not document training hours for each training. The following deficiencies were identified and the facility is issued a citation [See page LIC809-D for cited deficiencies]. An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to the licensee. This report will be emailed to Facility Administrator.

met_with: Sheryl Stone, HR Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 3-25-26, at 9: AM Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection, at the above-listed facility, for the purpose of conducting an Annual /Random Inspection. Licensing staff was met by Leah Salanoa Facility Administrator (FA) who granted access into the facility, and provided a tour of the entire facility, inside and out. This is a one-story home with three bedrooms, eight bathrooms, three therapy rooms, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. There are no firearms or dangerous weapons in the home. Medicines and all sharp knives are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. Required postings and Emergency Disaster Plan were observed, and there were materials available to clients to file grievances. LPA observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects (9) designated for Chef/Staff use are stored in a locked tool box, and within a locked gated cabinet in the rear portion of the kitchen. Chemicals and cleaning solutions are kept in locked cabinets. Continued on LIC809C Breakfast area: consists of a table with 8 chairs Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: 4 garage spaces but space is currently being used as storage and for recreation. The space is equipped with a basketball hoop, exercise equipment and plenty of locked cabinets for storage. There is an extra refrigerator and freezer in this area. Laundry area: equipped with a washer and dryer, and plenty of cabinet space cleaning supplies were locked and a fully charged fire extinguisher was observed. School: equipped with 6 desk and chairs, a printer and a station for an instructor. 3 bedrooms observed to each have individual bathroom, sufficient lighting, drawer and closet space. Each bedroom had two twin beds, clean linens, blankets, and pillows. Nursing station, Located in rear portion of the facility. There is a bathroom with two sinks and walking closet first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Group Therapy Rooms: Office Therapy Room: equipped with clean furniture in good repair. Second Therapy Room: equipped with furniture in good repair. The Exterior consists of the following: Pool: Located in the backyard, there is a fencing on the premises that meets regulations. During the time of inspection, LPA reviewed and completed the following sections of the Care Tool for Group Homes: Physical Plant, Operations, Emergency Procedures, Disaster Preparedness, Client Records, and Staff Records. Continue on LIC809-C Client/Staff Interviews: LPA conducted a confidential interview with: C1, C2, C3, FA, S1, S2, and S3. C4, C5, and C6 declined to be interviewed. Client/Staff File reviews: LPA conducted file reviews for: C1, C2, C3,C4, FA, S1, S2, and S3. Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulation, there are no deficiencies cited during this inspection. An exit interview was conducted, and FA was informed that the annual inspection was complete. A copy of this report was sent to the administrator via email.

met_with: Leah Salanoa, Facility Administrator (FA)


summary: Facility Evaluation

met_with: Leah Salanoa,Facility Administrator (FA)

narrative: On 3-25-26, at 9: AM Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection, at the above-listed facility, for the purpose of conducting an Annual /Random Inspection. Licensing staff was met by Leah Salanoa Facility Administrator (FA) who granted access into the facility, and provided a tour of the entire facility, inside and out. This is a one-story home with three bedrooms, eight bathrooms, three therapy rooms, a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, and a backyard. There are no facility cameras on the premises. There are no firearms or dangerous weapons in the home. Medicines and all sharp knives are inaccessible to children. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. Required postings and Emergency Disaster Plan were observed, and there were materials available to clients to file grievances. LPA observed the following during inspection: Living Room: with a securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with 8 chairs. Kitchen: equipped with a refrigerator, Built-In BBQ, Cooktop - Gas, Double Oven, Microwave, Breakfast Nook, Formal Dining Room, Kitchen Island a sink is located in the island, and plenty of cabinet space. Knives / Sharp objects (9) designated for Chef/Staff use are stored in a locked tool box, and within a locked gated cabinet in the rear portion of the kitchen. Chemicals and cleaning solutions are kept in locked cabinets. Continued on LIC809C Breakfast area: consists of a table with 8 chairs Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Garage: 4 garage spaces but space is currently being used as storage and for recreation. The space is equipped with a basketball hoop, exercise equipment and plenty of locked cabinets for storage. There is an extra refrigerator and freezer in this area. Laundry area: equipped with a washer and dryer, and plenty of cabinet space cleaning supplies were locked and a fully charged fire extinguisher was observed. School: equipped with 6 desk and chairs, a printer and a station for an instructor. 3 bedrooms observed to each have individual bathroom, sufficient lighting, drawer and closet space. Each bedroom had two twin beds, clean linens, blankets, and pillows. Nursing station, Located in rear portion of the facility. There is a bathroom with two sinks and walking closet first aid kit, and first aid supplies were observed. There is also a small refrigerator for storage of client medication that requires refrigeration. Group Therapy Rooms: Office Therapy Room: equipped with clean furniture in good repair. Second Therapy Room: equipped with furniture in good repair. The Exterior consists of the following: Pool: Located in the backyard, there is a fencing on the premises that meets regulations. During the time of inspection, LPA reviewed and completed the following sections of the Care Tool for Group Homes: Physical Plant, Operations, Emergency Procedures, Disaster Preparedness, Client Records, and Staff Records. Continue on LIC809-C Client/Staff Interviews: LPA conducted a confidential interview with: C1, C2, C3, FA, S1, S2, and S3. C4, C5, and C6 declined to be interviewed. Client/Staff File reviews: LPA conducted file reviews for: C1, C2, C3,C4, FA, S1, S2, and S3. Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulation, there are no deficiencies cited during this inspection. An exit interview was conducted, and FA was informed that the annual inspection was complete. A copy of this report was sent to the administrator via email.


facility_name: NEWPORT ACADEMY-FRENCH CREEK

raw_content:
Narrative:
During interviews with the Residential Supervisor, Residential Manager, and therapist in the facility, it was reported that C1 had a history of making false statements against and targeting peers prior to being placed at this facility. Staff stated C1 was a resident at another facility for this agency and was moved to this location in hopes to allow C1 to make a new start in a fresh environment. Knowing C1's history, C1 was placed on heightened supervision since their arrival to this facility but not on a one-to-one supervision. Staff admitted that the supervision for C1 was not elevated to one to one as the previous false statements against peers was not of a sexual nature prior to their placement. Staff were aware that C1 needed to be closely monitored. During the approximately one week where C1 and C2 were roommates, the facility did only have one staff supervising youth during the overnight hours and the overnight staff had other duties to be completed during their shift that would take them away from the area where the clients' rooms were located. This left the client rooms unsupervised for periods of 10 to 15 minutes. Confidential interviews with overnight staff indicated that once they became aware of the allegation, they ensured that the area where client rooms were located was never left unsupervised, even for restroom breaks or other rest periods. Overnight staff interview indicated that both youth were sounds sleepers and that there was never a time that youth were awake or woke up while they worked the overnight shift, including the night(s) the alleged allegation occurred. Confidential interviews with youth were not consistent on whether there was any sexual contact between them. As a result of the information obtained and reviewed and interview conducted, the allegation that a lack of supervision resulted in an inappropriate interaction between youth is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and documents, including appeal rights, were provided to Mr. Parraz.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 5/29/25 at 1: PM and met with David Parraz, Residential Supervisor to discuss the findings of the allegation stated. LPA Hill informed Mr. Parraz that the complaint inspection included an initial inspection at the facility on 4/10/24 and a subsequent inspection on 4/23/25 where information was obtained about clients in care and other incident(s) and interviews were conducted with C1, C2, and staff at the facility. Additional interview with the overnight awake staff was conducted on 5/29/25. LPA Hill informed the agency that the allegation that a lack of supervision resulted in an inappropriate interaction between youth in care is a result of an incident reported by the agency alleging that C1 was sexually assaulted during the overnight hours and on more than one occasion by C2 while they were roommates, within days of the youth being admitted to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: NEWPORT ACADEMY-FRENCH CREEKFACILITY NUMBER: VISIT DATE: 05/29/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: David Parraz, Residential Supervisor


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced Prelicensing inspection on 12/21/21 at 12: PM and met with Pamela Alba, Regional Executive Director and Cassidy Salmina, Residential Supervisor to conduct the prelicensing inspection. LPA observed that the required posting are present in the home and includes personal rights, complaint poster, Ombudsperson poster, grievance policy, COVID-required precautions and grievance procedures.. LPA observed that the home is equipped with three dual occupancy client rooms, five restrooms with five showers, three therapy rooms, one locked medication room, one staff office, and one kitchen that is stocked with cooking supplies and place settings for all six clients and staff. LPA observed that there are six fire extinguishers located throughout the home - LPA did advise the facility to contact the local fire inspector to have the extinguisher inspected and tagged as needed. LPA toured the outside of the facility and observed that there are no health and safety concerns for the outdoors. LPA observed that the outdoor space is appropriate for the clientele to be served. LPA observed that the chemicals are to be stored in a locked closet near the kitchen area. Sharps are to be located under the kitchen sink in a locked cabinet. Medications are stored in a locked medication room and the facility plans to have a locked medication cart where the medications will be stored inside the locked medication room. LPA observed that there is hot water where all clients have access in the bathrooms. LPA observed that the bathroom toilets were functioning as required. All bathrooms were stocked with paper towels as required. LPA reminded the facility that the use of common towels is not allowed in bathrooms that are shared by more than one client. LPA observed that there is a classroom on the premises as well as a gym for client use. LPA observed that the laundry rooms is available to clients and laundry supplies are to be locked and inaccessible to clients. LPA observed that the facility is still trying to get the phone line hooked up as there was an issue with the installation on 12/20/21. LPA observed that the facility has four cell phones available for staff and these phones are available for youth to use until the land line is installed and working. LPA observed that the facility is ready for licensure as soon as the phone is hooked up and working. LPA is recommending that the facility be issued their license upon review of management. Exit interview was conducted with Ms. Alba and Salmina and document provided via email.

met_with: Pamela Alba, Regional Executive Director & Cassidy Salmina, Residential Supervisor


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced post licensing inspection on 3/16/22 at 12: PM and met with Michelle Good, Residential Director. LPA toured the facility inside and out and observed that the agency is in the process of paving the driveway to a lower level parking lot that will be utilized for staff person parking. LPA also discussed the lower house and outbuilding with the facility and was informed that the proposal was put forth today to convert the lower house to a gym for client use. LPA informed the facility that prior to it being utilized by clients, LPA needs to inspect the building and it needs to have a fire clearance approved by the Department. LPA informed the facility that plans for the construction, new facility sketch showing these buildings and their purpose(s), along with building permit(s) need to be submitted to Licensing prior to commencement of work. LPA observed that the smoke detectors and carbon monoxide detector are working as required. LPA observed that the facility had sufficient food in the facility for the amount of clients in care. LPA observed that client rooms are clean and safe for clients and have the proper furnishing for clients. LPA observed that there is adequate food for the clients in care. LPA reviewed client files while at the facility and due to the time restriction was not able to review staff files. LPA did inform the facility that LPA will return to continue the visit on another day. LPA did provide technical advisories for ambulatory status, tuberculosis tests, and room sharing compatibility for clients who share rooms. Exit interview was conducted.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced post licensing inspection on 3/17/22 at 1: PM and met with Michelle Good, Residential Director. While LPA was conducting a prelicensing at the agency's other house, LPA and Ms. Good conducted a teams meeting with Human Resources via MS Teams to go through staff records. LPA observed some major issues with the personnel records. LPA informed Ms. Good that the documentation related to those issues will be issued on another date as LPA needs to go through the required documentation and citations. LPA informed Ms. Good that the Post Licensing inspection shall continue on another date. At that time, LPA will conduct interviews with staff and clients. Exit interview conducted and only this document was provided to Ms. Good on this date.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill continued an unannounced post licensing inspection on 4/5/22 at 3: PM and met with Michelle Good, Residential Director. The inspection on this date was to complete the Post Licensing inspection, that was initiated on 3/16/22, continued 3/17/22 where LPA reviewed personnel records via Microsoft Teams and concluding on 4/5/22. LPA informed Ms. Good that the 3/17/22 inspection was conducted via Microsoft Teams due to the agency not having a personnel person available in this region yet. LPA identified some issues with personnel records and the facility is being provided with the following: The agency stores all of their staff files electronically only but there is no personnel working out of this region that has access to the records to ensure that the appropriate documentation is obtained and stored according to the regulations. The staff that provided access to the records reviewed is from another region of the state and states that she is attempting to complete the appropriate records as the personnel working in their human resources for this region recently quit the agency. LPA observed that the following items are missing from staff files: Proof of training - there were no records found in staff files about any training as required - initial 8 hour and 16 hour training 84065(i) and applicable documented assessment(s) including job shadowing (84065(i)(1)(C)(4), First Aid 80075(f), Cardiopulmonary Resuscitation (CPR) 84065(i)(6), medications training, facility manager training per 84065(d)(3). (Reviewed 5 staff files) Proof of Tuberculosis testing only one staff had proof of TB 80066(a)(11) Medical Assessment Documentation 80066(a)(10) was missing in 3 of 5 staff records requiring indication of the presence of any health condition that would create a hazard to the person, clients or other staff members 80065(g)(2)(B) Criminal Record Statement - One staff was missing this document in their file 80066(a)(12)(A) Personnel evaluations were not present in any of the files per 84066(b)(6) Facility was cited for Personnel Records 80066(a) as records are required to be maintained for all employees and must have all required documentation. Facility was cited for 84065(i)(6) as not all staff had proof of First Aid/CPR as required. Documentation was provided to Ms. Good and exit interview conducted.


summary: Facility Evaluation - 1 deficiency

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill and Kevin Gaines, Community Care Licensing Division Representative made an unannounced annual inspection on 11/7/22 at 9: AM. LPA and Representative toured the facility inside and out and reviewed client records during the annual inspection. It was observed that there were three clients in care at the facility and there were two staff present and one teacher was present during the inspection. LPA and Representative observed that there were three dual occupancy client rooms in the facility but each of the clients currently are occupying a room. LPA observed that the smoke detectors and carbon monoxide detectors were functioning as required. LPA observed that the facility was clean and tidy during the inspection. LPA observed that the facility's water was not hot enough - measuring only 100 degrees Fahrenheit and measurements were taken in the kitchen and two client bathrooms. LPA observed that the facility is not providing allowances as required. LPA observed that the clients are not attending meetings related to needs and services or modifications of needs and services, which lends to clients not having an opportunity to have a voice in their treatment. LPA observed that one of the client bathrooms had towels hanging that could be used by other clients and common towels are not allowed. LPA observed that the rugs in the same bathroom slide and are not secure as required. LPA observed that the complaint/grievance policy is not posted as required. During client records reviewed, it was observed that the facility is not obtaining written documentation of the educational records for the clients in care. While only one client in the facility is taking psychotropic medication, there is no written authorization for this specific medication to be administered to client in care. Citations are attached and exit interview conducted with Ms. Bertolino and Michelle Good and documents provided along with appeal rights.

Deficiencies:
84068.2(b): Needs and Services Plan

(b) The needs and services plan shall identify the child's needs in the following areas

met_with: Bre Bertolino, Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 1/18/23 at 2: PM and met with Breana Bertolino, Administrator and Corey Montoya, Clinical Director. LPA discussed an incident report dated 1/2/23 in which a fight ensued in the facility and law enforcement was called to assist the facility in breaking up the incident. LPA discussed the documentation in the incident report that was submitted in that it appears that the facility discharged the youth without attempting to mitigate the removal of the youth and without a seven day notice to the placing agency per the program statement that was approved by the Department. LPA discussed with the administrator that when discharging a youth, the facility needs to provide a written seven day notice to the client's guardian and/or placing agency. LPA explained that there are circumstances when a youth should be discharged under emergency situations and that would be removal by law enforcement, hospitalization or other emergent situations. In this particular incident, LPA sees that a youth was discharged but there does not appear to be any other incidents involving this youth nor does it appear that the youth failed to calm down or take space after speaking with law enforcement. While discussing the incident with Ms. Bertolino, LPA was informed that there have been other issues of aggression with this youth but that it did not rise to the level of a report to Licensing. LPA informed the facility that providing all of the information and information utilized to reach the conclusion is necessary for the Department to understand and ensure that the facility is following their own program statement. Ms. Bertolino states that she will ensure that the incident reports moving forward are more comprehensive and have the information necessary that lead the facility to reach the conclusion that was reached. Exit interview conducted with Ms. Bertolino and Ms. Montoya.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPAs) Mary Shelton and Monica Roberts made an unannounced annual inspection on 12/7/2023. LPA Mary Shelton and Monica Roberts toured the facility inside and out and reviewed staff and client records during the annual inspection. It was observed that there were six clients in care at the facility and there were four staff present and one teacher was present during the inspection. LPAs observed that there were four dual client rooms in the facility. There were two bedrooms with two clients and two bedrooms with single clients. LPA observed that the smoke detectors and carbon monoxide detectors were functioning as required. The LPAs observed that the facility was clean and maintained during the inspection. LPA observed that the facility's water was at required temperatures at all faucets within the home. LPAs observed the temperature of the home to be 72 degrees.LPA observed that the rugs are secure as required. All sharps and chemicals were properly secured. LPA observed that the complaint/grievance policy is posted as required. Exit interview was conducted with Ms. Bertolino.

met_with: Breana Bertolino, Residental Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Mary Shelton made an unannounced Case Management - Annual Continuation inspection on 12/15/2023. LPA observed the clinic which included medical records for clients and medication. LPA inspected the Medication County Log and the Controlled Medication Log. It was observed that there were six clients in care at the facility, there were four staff present and one teacher was present during the inspection. The LPA observed that the facility was clean and maintained during the inspection. LPA Shelton interviewed three clients and two staff for the purpose of the inspection. No deficiencies were observed during the inspection Exit interview was conducted with Ms. Bertolino and a copy of this report was proved. Due to technical difficulties LPA was not able to use the electronic Care Tool.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Michelle Silvas made an unannounced annual inspection on 10/17/24 at 1: PM and met with Ben Connolly, Residential Supervisor. LPAs toured the facility inside and out and observed that the facility has three dual occupancy rooms on the lower level of the facility. On the main floor, the agency has several therapy rooms, restrooms, kitchen, laundry room, pantry area, and gym room. LPAs observed that the down stairs client rooms had a bathroom for each of the bedrooms and that each of the bathrooms were equipped with showers, toilets, and hand washing facilities. LPAs observed that the toilets flushed, showers were operating and that the handwashing facilities deliver hot water as required. LPAs did observe that the bathrooms for two of the bedrooms had common towels during the inspection and did issue an technical advisory regarding this. LPAs did not cite as these two bedrooms are single occupancy at this time. LPAs observed that the facility had an adequate supply of perishable and nonperishable food to provide for the youth in care. LPAs observed that the kitchen areas, including the refrigerator and freezers were clean, with all food items labeled as required. LPAs observed that the facility had a dishwasher for the sanitizing of dishes when used. The facility had a medication room that was locked and inaccessible to youth in care. LPAs observed that the first aid supplies meets requirements and was equipped with all items required by the regulations. LPAs observed that the smoke detectors were functioning and that there was a working carbon monoxide detector on each level of the facility. LPAs observed that fire extinguishers were observed in numerous locations throughout the facility and that they were last inspected on 2/13/24. LPAs reviewed the Mass Casualty and Disaster Plan and is in compliance with Health and Safety as required. LPAs observed that the facility has installed locks on the exit doors (2) that gives access to the patios on the main level. LPA Hill advised that the agency may need to contact the local fire district to alert them of the newly installed locks. This may be a violation of the fire clearance granted. The agency shall inform the Department of the information obtained from the local fire jurisdiction. As a result of the annual inspection, there were no citations issued but the agency was issued a Technical Violation for Fixtures, Furniture, Equipment and Supplies, 84088(c)(2)(B) for the use of common towels in the restrooms. LPAs observed that two of the client bathrooms had towels in their bathrooms. LPAs observed that the clients in the bedrooms did not have roommates but is advising the agency that leaving the towels in the restrooms is not a good practice. Exit interview was conducted and documents were provided.

met_with: Ben Connolly, Residential Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Michelle Silvas made an unannounced case management - annual continuation on 10/18/24 at 10: AM and met with Dinnielle Saravia, Residential Supervisor to review client files. LPAs reviewed client electronic records with the assistance of Ms. Saravia. LPAs reviewed client medications and medication records and conducted interviews with clients and staff during the inspection. LPAs advised the agency that they are required to have individual written policies regarding Discharge and Removal and Discipline that are required to be signed by parent/guardian and child and maintained in the client file. Exit interview was conducted with Ms. Saravia and documents were provided during the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/21/25 at 10:15 am and met with Ben Connolly, Residential Manager, and Kristina Harris, Counselor. LPA Hill conducted the inspection to discuss an incident report, dated 1/31/25, related to a medication error. LPA Hill spoke to Mr. Connolly about the incident and subsequent documentation. LPA Hill learned that youth had recently had a dosage change, lessening the dosage of the medication prescribed, but the lesser dosage of that medication was not administered appropriately. Instead, youth was given the previously prescribed dosage of that medication. LPA Hill discussed with the agency that in documentation of medication errors, staff should be documenting what actions are taken by the agency when identifying an error in the administration of the medication including but not limited to additional training provided, staff disciplinary action, or other actions taken by the agency to ensure these types of incidents do not occur again in the future. LPA Hill learned that staff responsible for the error is out on medical leave at this time and prior to staff's return to the agency and administering medications, staff shall receive additional medication training. Exit interview was conducted and documentation was provided.

met_with: Ben Connolly, Residential Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an initial case management inspection to the facility on 7/3/25 at 3: PM and met Dinnielle Saravia, Administrator to discuss an incident report. LPA Hill informed Ms. Saravia that the inspection is being conducted as a result of an incident report dated 6/20/25 in which C1 (see LIC811 dated 7/3/25) allegedly found an item on the facility grounds that may be dangerous to youth in care. In addition, the incident report details C1 being "wanded" and required to do a "contraband dance" as a result of the find. LPA Hill discussed the incident with staff including supervision at the time of the "find". It was reported that C1 was within eyesight of staff when C1 found the item(s) and turned them over to staff. C1 was "wanded" which includes a search of C1's person with the use of a metal detecting wand and C1 was required to perform a "contraband dance" which includes turning out of their pockets, and jumping up to ensure that youth did not have any unauthorized items that may come loose or drop. These actions could be seen as potential violations of C1's right to be free of unreasonable searches and as a result, the facility was issued an Advisory Note for Personal Rights. In addition, LPA Hill informed Ms. Saravia that in review of the Plan of Operation approved for the agency, a "contraband dance" was not articulated and thus not approved by Community Care Licensing. Facility was cited for violation of Title 22, Section 80022(b)(1) Plan of Operation as the agency is required to have a plan of operation that includes program methods including how, when and under what circumstances searches are to be conducted and this policy must be approved by Community Care Licensing. Exit interview conducted and documentation was provided, along with appeal rights.

met_with: Dinnielle Saravia, Administrator