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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004302
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:45:15 PM


Document Has Been Signed on 06/13/2024 03:45 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 IIIFACILITY NUMBER:
306004302
ADMINISTRATOR:BRUCE WINSTEADFACILITY TYPE:
740
ADDRESS:2412 HOLLY LANETELEPHONE:
(714) 351-7800
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Chris LandonTIME COMPLETED:
03:02 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Newport Senior Living III. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 5 residents and the home currently has 6 residents, with 5 on hospice. Administrator Chris Landon arrived during the visit.
LPA Lyman along with Administrator Chris Landon toured the facility at 12:45 PM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, 6 resident bathrooms, one staff room, living room, dining room, and kitchen. Facility has an apartment connected to facility and LPA observed occupant has criminal record clearance. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed six residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106.5 and 107.4 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the elements including thermometer, tweezers and scissors. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 02/26/2024. CONT ON LIC809-C DATED 06/13/2024
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 III
FACILITY NUMBER: 306004302
VISIT DATE: 06/13/2024
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Facility provides activities in the form of exercise and games. At 1:30 PM, LPA reviewed six resident files and two staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, medical clearance/ TB, CPR training and criminal record clearance. At 2:00 PM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit ,NO violations are being cited. Exit interview 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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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