<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004302
Report Date: 05/18/2022
Date Signed: 05/19/2022 06:52:41 AM


Document Has Been Signed on 05/19/2022 06:52 AM - 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 IIIFACILITY NUMBER:
306004302
ADMINISTRATOR:BRUCE WINSTEADFACILITY TYPE:
740
ADDRESS:2412 HOLLY LANETELEPHONE:
(714) 351-7800
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:6CENSUS: 6DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Bruce WinsteadTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Licensee Bruce Winstead was present.

At 11:43 AM, LPA toured the facility with Licensee Winstead. Facility has 6 residents in care during today's visit with 2 on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. LPA observed the residents participating in music therapy. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer as well as hand washing signage. All rooms are single occupancy with private restroom. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures multiple times daily and documents results. LPA observed ample sanitizer spread out throughout the facility. Facility has covid precaution postings as well as all required department postings. Administrator Chris Landon has an administrator certificate expiring on 12/27/2023. Facility mitigation plan has been approved. LPA observed the emergency disaster plan posted in facility. LPA observed an ample supply of emergency food and water stored in the garage. Smoke detectors tested operational during today's visit as well as fire extinguishers are fully charged. LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files are up to date. All residents and staff are vaccinated for Covid-19.
LPA consulted with Licensee on the importance of maintaining N95 masks on-site at the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1