306004302-12-1-2021-22-AS-AORZ-C9SSVK-20211217131250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004302
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:23:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210723102458

FACILITY NAME:	NEWPORT SENIOR LIVING III		FACILITY NUMBER:	306004302
ADMINISTRATOR:	BRUCE WINSTEAD		FACILITY TYPE:	740
ADDRESS:	2412 HOLLY LANE		TELEPHONE:	(714) 351-7800
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Chris Landon		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Lack of supervision resulting in resident choking.
Staff did not respond to resident's call button in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility by Caregiver BG Oliva and explained the reason for the visit. Administrator Chris Landon and Licensee Bruce Winstead arrived during the visit.
During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report, appraisal needs and services, and autopsy report. Regarding the allegation that lack of supervision resulted in resident choking and staff did not respond to resident’s call button in a timely manner, the investigation revealed the following:
On 07/10/2021, Staff 1 (S1) brought dinner into Resident 1’s (R1) room around 5:19 PM. Approximately 15 minutes later, sometime between 5:35 PM and 5:45 PM, R1 used a call button indicating that the they needed assistance. S1 responded and observed R1’s face was blue/ purple in color and appeared to be choking. S1 called for S2 to assist. S1 performed the Heimlich maneuver for about 5 minutes while waiting for paramedics to arrive. CONTINUED ON 9099C DATED 12/01/2021

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 4

Control Number 22-AS-20210723102458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 306004302
	VISIT DATE: 12/01/2021

NARRATIVE

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Orange County EMS report obtained notes the incident as taking place at approximately 5:39 PM. Paramedics arrived on the scene around 5:43 PM and were unsuccessful in reviving resident. R1 was pronounced deceased at the scene at 6:04 PM by the responding paramedics. R1’s medical examiner’s report dated 07/14/2021 lists R1’s cause of death as asphyxia due to upper airway obstruction, food bolus aspiration. A police report obtained from local police reveal responding officers were called at approximately 6:09 PM to investigate the deceased resident. The responding officer did not observe any signs of struggle or anything unusual. No signs of physical injuries were noted.
Witnesses interviewed reported the meal provided that day was chicken cut up in small pieces and a salad. Both caregivers present at time of incident reported they responded immediately to the resident’s alert. During an initial visit to the facility, LPA Lyman observed the facility call system. All residents have a motion detector in their room as well as a pendant. When a resident moves or pushes the pendant, the centralized system goes off in the kitchen. The alert goes off until the staff manually reset the system. There are no print outs or a time stamp to verify what time the system went off or when staff responded during the incident.

R1’s responsible party reported R1 had a near choking incident with a few days prior during an lunch outing together. R1’s Responsible party reported they had notified staff about the incident upon returning R1 to the facility that same day. Both administrators and two of three staff interviewed deny any knowledge of a prior choking incident. The remaining staff member reported vaguely recalling a conversation with the responsible party regarding R1’s near choking incident while out to lunch with the R1’s responsible party and stated they instructed R1’s responsible party to discuss it with the facility Administrator. All staff indicate no knowledge of a change in supervision requirements or dietary restrictions. All staff interviewed denied ever observing R1 have issues while eating.
R1’s physician report dated 04/02/2021 and Appraisal Needs and Services dated 04/20/2021 list R1 as able to feed themself. The appraisal states R1 needs medium to maximum assist in all ADL’s related to the lower body only. Hospice records reviewed did not notate a need to supervise R1 while eating.

Based on multiple interviews conducted and documents reviewed, there is not enough evidence or corroborating information to support the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was left at the facility.
Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210723102458

FACILITY NAME:	NEWPORT SENIOR LIVING III		FACILITY NUMBER:	306004302
ADMINISTRATOR:	BRUCE WINSTEAD		FACILITY TYPE:	740
ADDRESS:	2412 HOLLY LANE		TELEPHONE:	(714) 351-7800
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Chris Landon		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff did not follow resident's dietary orders.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Caregiver BG Oliva and explained the reason for the visit. Administrator Chris Landon and Licensee Bruce Winstead arrived during the visit.

During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report, appraisal needs and services, and autopsy report. Regarding the allegation that Staff did not follow resident’s dietary orders, the investigation revealed the following:

Per Resident 1’s (R1) Appraisal Needs and Services dated 04/20/2021, the resident has the following dietary restrictions: no pork; cannot have meat and dairy at the same time; allergic to shellfish; and eats kosher. The appraisal needs and service form was signed by both the facility Administrator and R1’s responsible party. CONTINUED ON LIC 9099 DATED 12/01/2021

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20210723102458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 306004302
	VISIT DATE: 12/01/2021

NARRATIVE

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Hospice records obtained and reviewed do not indicate any dietary restrictions for R1. R1’s physician report dated 04/02/2021 list R1 as able to feed themself. All staff interviewed reported R1 had no issues observed while eating prior to the 7/10/2021 choking of R1.

Therefore, based on the records reviewed and interviews conducted, the allegation is deemed UNFOUNDED, meaning the allegations is false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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