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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005154
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:50:36 PM


Document Has Been Signed on 04/12/2022 03:50 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 BEACH MEMORY CAREFACILITY NUMBER:
306005154
ADMINISTRATOR:HADLEY, BRIANFACILITY TYPE:
740
ADDRESS:1000 HALYARDTELEPHONE:
(949) 220-9700
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:42CENSUS: 22DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Chanel SanchezTIME COMPLETED:
12:30 PM
NARRATIVE
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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. Chanel Sanchez has an administrator certificate expiring on 07/06/2023.

At 9:56 AM, LPA toured the facility with Administrator Chanel Sanchez. Facility has 22 residents in care during today's visit with 7 residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility utilizes a hand written visitor sign in sheet. Facility takes resident temperatures daily and documents. LPA observed the first aid kit has all required items including tweezers and scissors. LPA observed sufficient supply of emergency food as well as emergency supplies. Facility does not have emergency water in place. LPA observed multiple shaded outside visitation areas. Facility is approved for delayed egress. Facility contracts an outside agency, Fire Safety First, for fire sprinkler and smoke detector safety. Last visit was on 08/16/2021. At 10:20 AM, LPA observed all three stairwells do not have an evacuation chair. LPA observed the locked medication room. Facility utilizes an electronic medication administration record. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files have updated emergency information. LPA observed two out of three residents with Dementia do not have an updated physician report.

During the visit, LPA consulted with Administrator regarding the importance of taking staff temperatures daily and documenting. Additionally, LPA advised on the importance of hand washing signs in all common restrooms.
Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
Exit interview conducted and a copy of the appeal rights were given at time of visit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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 3


Document Has Been Signed on 04/12/2022 03:50 PM - It Cannot Be Edited

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 BEACH MEMORY CARE
FACILITY NUMBER: 306005154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(f)(1)
A facility shall have both of the following in place:
(1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three out of three stairwells. All three stairwells do not have an evacuation chair which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Please obtain evacuation chairs for all three stairwells and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/12/2022 03:50 PM - It Cannot Be Edited

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 BEACH MEMORY CARE
FACILITY NUMBER: 306005154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure... including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Facility does not have any emergency water on-site which poses a potential health and safety risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Licensee to obtain emergency water and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three physician reports. R1 and R3 do not have updated physician reports. This poses a potential health and safety risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Licensee to obtain updated physician reports and forward proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3