306005154-8-17-2023-22-AS-AORZ-CVNTP9-20230914145359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:19:23 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/14/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230814133520

FACILITY NAME:	NEWPORT BEACH MEMORY CARE		FACILITY NUMBER:	306005154
ADMINISTRATOR:	HADLEY, BRIAN		FACILITY TYPE:	740
ADDRESS:	1000 HALYARD		TELEPHONE:	(949) 220-9700
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	42	CENSUS: 19	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kevin Fox, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff does not have proper training to care for resident in care.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by the facility's Operations Manager before listing the allegation.

LPA requested and reviewed records for resident R1. The physician report based on an examination dated February 9, 2023 indicates that resident is diagnosed with dementia and has a colostomy bag installed. Due to the dementia diagnosis, the resident is not mentally and physically capable of providing all routine care for the ostomy. Following the resident's admission on May 28, 2023, the ostomy was attended to by skilled professionals under an admission with Apex Home Health. Following an incident with one of the providers sent by Apex, the resident was discharged from the service after July 15, 2023 and before August 10, 2023.

CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230814133520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NEWPORT BEACH MEMORY CARE	FACILITY NUMBER: 306005154
	VISIT DATE: 08/17/2023

NARRATIVE

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CONTINUED FROM FROM LIC9099

After the Home Health discontinuation of care, supervision of the resident's ostomy was taken over by staff member S1 Wellness Director who was in possession of an active nursing license. After the former Executive Director was terminated, S1 submitted their resignation as well. At that time, the supervision of the ostomy was taken over by the facility's interim LVN on call from the Skilled Nursing Facility operated by the same licensed entity and located across from Newport Beach Memory Care. Documentation of the interim LVN's endorsement was provided to LPA during the visit, in addition with email exchanges with the resident's care manager. A physician order for the admission of the resident into Hoag Home Health was obtained on August 15, 2023 and submitted to the provider on the same day. The ostomy bag was also observed to be clean and was replaced on August 15, 2023.

The investigation confirmed continuity in the routine care of R1's ostomy bag by skilled professionals as required by the California Code of Regulations Section 87621. As a result, the allegation that Staff does not have proper training to care for resident in care is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint.

A consultation on the requirements for the admission of residents with Restricted Health Conditions was provided to the facility's representative through a Technical Assistance Advisory Note, in an attached form LIC9102.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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