306005154-1-26-2024-22-AS-LMOA-D2WU7W-20240229142037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:45:42 PM

Substantiated

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:	12:00 PM
MET WITH:	Karen Ashley - Wellness Director		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Facility's staff is insufficient to adequately provide care and supervision to the residents in care

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 on January 17, 2023 and today's follow up visit.

Regarding the allegation: Facility's staff is insufficient to adequately provide care and supervision to the residents in care

5 of 5 staff interviews confirmed there is a need for additional staffing. During interviews it was discovered that there has been staffing issues. Caregivers have called off and quit before a scheduled shift without notice. Staff 4 (S4) said the staffing has gotten better and the help from the staffing agencies has
Continued on LIC9099C

Substantiated

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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become more consistent. Staff 2 (S2) and Staff 5 (S5) both said there are days when there’s enough staff and there’s days when there is not enough staff.

Based on the evidence gathered through interviews, observation, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted and a copy of this report and appeal rights were 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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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/02/2024 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Wellness Director Karen Ashley agrees to review regulation section 87705 Care of Persons with Dementia and send a signed statement or understanding once completed. Wellness Director Ashley will also send a plan of action that details what will be done to prevent a lack of staffing in the future. POC will be emailed to LPA Haley by Friday, February 2, 2024 at 1:00PM.
	8 9 10 11 12 13 14	The requirement is not being met as evidenced by the presence of only two staff members working and the Wellness Director covering for a Med Tech who called off during a January 17, 2024 initial complaint visit.	8 9 10 11 12 13 14
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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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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