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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005154
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:52:24 PM


Document Has Been Signed on 01/26/2024 02:52 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:
01/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karen Ashley - Wellness DirectorTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20240109140428.

During the complaint investigation mentioned above, it was discovered Staff 1 (S1) was not fingerprint cleared and listed on the facilities personnel roster. S1 has been working at the facility for a year and was never officially cleared to work because the application process was never completed.

Recently the facility has hired four new staff members. One new hire is clear and will be starting soon. The remaining three new hires start date is pending their fingerprint clearance.

As a result of today’s Case Management visit, deficiencies will be cited.

An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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 2


Document Has Been Signed on 01/26/2024 02:52 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: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) "All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..."
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Wellness Director Karen Ashley will review regulation section 87355 Criminal Record Clearance and sign a statement of acknowledgement of understanding upon completion. Staff 1 has been removed from the schedule and will not return to work until the application process is completed and S1 is clear and associated to the facility.
POC Due date is Tuesday, January 30, 2024.
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This requirement is not met as evidenced by:
Based on observations and interviews, S1 was not fingerprint cleared prior to working or visiting the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2