306005154-1-26-2024-22-AS-LMOA-D2WU7X-20240229142037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:45:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/09/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240109140428

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: 22	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Karen Ashley - Wellness Director		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Facility failed to ensure the safety of residents in care after admitting a new resident with behavior issues

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit.
The complaint investigation consisted of interviews with facility staff, witnesses, and observations made during the initial visit and the follow-up visit.

Regarding the allegation: Facility failed to ensure the safety of residents in care after admitting a new resident with behavior issues.

5 of 5 staff members interviewed denied Resident 2 (R2) had behavior issues. During the investigation it was discovered that R2 does like to touch people and things around him; however, he has no intent to harm or hurt anyone. Staff 1 (1) said R2 doesn’t bother anyone and his touching is normal. Staff 2 (S2)
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240109140428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/26/2024

NARRATIVE

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said R2’s touches are soft and the resident is like a baby. All of the staff interviewed denied R2 has behavior issues.

Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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