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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004278
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:49:48 PM


Document Has Been Signed on 10/17/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:NEWPORT SENIOR LIVING IIFACILITY NUMBER:
306004278
ADMINISTRATOR:BRUCE A. WINSTEADFACILITY TYPE:
740
ADDRESS:260 E. 16TH STREETTELEPHONE:
(949) 650-2222
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 6DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Bruce Winstead, Deanna LandonTIME COMPLETED:
03:00 PM
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On 10/17/2022 at 12:52pm, Licensing Program Analyst (LPA) Jessica Cho arrived at Newport Senior Living II to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 1:00pm, LPA Cho was greeted and granted entry by Caregiver Alberto Belmont and completed the Coronavirus 2019 (COVID-19) screening procedure. Caregivers Elizabeth Contreras and Guadalupe Cubias De Orell were also present during today's visit. At 1:06pm Administrator (Admin) Deanna Landon arrived at the facility. LPA greeted Admin and stated the purpose of today's visit. LPA reminded that the annual licensing fee is due by 11/30/2022. There are no active COVID-19 cases as of today. Facility screens and documents temperatures of visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) measured at 16"x20" which did not meet the size requirement. The Administrator's Certificate for Deanna Landon expires on 12/27/2023. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which three are receiving hospice care.

At 1:18pm, LPA Cho conducted a tour of the physical plant with Admin Deanna Landon. The single story home consists of six resident bedrooms and three resident bathrooms. There is one private staff bedroom in the facility. There is a garage in the backyard which has been converted into a private staff living quarters and has the facility laundry room. The facility also has a living room and kitchen. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured at 110.4 degree Fahrenheit in Bathroom #1, 110.3 degree Fahrenheit in Bathroom #2, and 109.9 degree Fahrenheit in Bathroom #3.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT SENIOR LIVING II
FACILITY NUMBER: 306004278
VISIT DATE: 10/17/2022
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LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 11/02/2021. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. There was a garage with a laundry room. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. LPA observed sufficient supply of emergency food/water and PPEs.

Around 2:10pm, Licensee Bruce Winstead arrived at the facility. At 2:35pm, LPA consulted the following with Licensee Winstead and Admin Landon: to enlarge and post the PUB475 in the Department size requirement by the entry way.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Administrator Deanna Landon, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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