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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:19:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/31/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230131162326
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: 20DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Erin Rehbein, Director of Marketing
Stephanie Garcia Rios, Wellness Director
Rogelio Martinez, Maintenance Director
Michelle Goodney, Administrator		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2/ Staff do not maintain a comfortable temperature for residents in care.

3/ Staff did not ensure that resident was provided their medication in a timely manner.

5/ Staff do not ensure that residents are provided with activities while in care.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Michelle Goodney after explaining the purpose of the visit and listing the allegations.

An initial visit was conducted on February 3, 2023. A tour of the physical plant was conducted with the administrator, and temperature measurements were taken. A sample of staff training records were reviewed. Staff schedules reviewed. Previous temperature measurements were taken during facility visits on January 4 and January 17, 2023.

Seven additional staff interviews were conducted during an investigation visit for complaint reference #22-AS-20221228101134 on March 6, 2023.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 22-AS-20230131162326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT BEACH MEMORY CARE
FACILITY NUMBER: 306005154
VISIT DATE: 04/14/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099
A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed.

Regarding the allegation that Staff do not maintain a comfortable temperature for residents in care, the following has been concluded: After a similar allegation was made as part of complaint 22-AS-20221228101134 filed on December 28, 2022, temperature measurements were taken during multiple facility visits on January 4, January 17 and February 3, 2023 as well as during today's visit. Facility received a citation in regard to the faulty heating units. Based on following observations and interviews conducted, there was not sufficient evidence to confirm that the issue was still ongoing. As a result, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Staff did not ensure that resident was provided their medication in a timely manner, the following has been concluded: LPA observed MedTech staff while touring the facility and reviewed print-outs of the Medication Administration Records for the months of March and April for a random sample of five residents out of 20 currently present within the facility. All daily doses are observed to have been administered correctly and typed into the system adequately. The allegation is therefore deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Staff do not ensure that residents are provided with activities while in care, the following has been concluded: During the initial visit, facility staff was observed wrapping up activities as listed and residents resting. Further interviews with the facility's Activities Director confirmed that activities were being offered to residents on each weekdays when Director is present, but that was not generally the case on weekends due to the responsible staff member not being scheduled on those days and care staff not having the availability to pitch in significantly. Administrator states that more dedicated staff may be hired if and when facility census gets higher. Therefore, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was reviewed and left to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/31/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230131162326

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: 20DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Erin Rehbein, Director of Marketing
Stephanie Garcia Rios, Wellness Director
Rogelio Martinez, Maintenance Director
Michelle Goodney, Administrator		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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4/ Staff are not not sufficiently trained.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Michelle Goodney after explaining the purpose of the visit and listing the allegations.

An initial visit was conducted on February 3, 2023. A tour of the physical plant was conducted with the administrator, and temperature measurements were taken. A sample of staff training records were reviewed. Staff schedules reviewed. Previous temperature measurements were taken during facility visits on January 4 and January 17, 2023.

Seven additional staff interviews were conducted during an investigation visit for complaint reference #22-AS-20221228101134 on March 6, 2023.
CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20230131162326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT BEACH MEMORY CARE
FACILITY NUMBER: 306005154
VISIT DATE: 04/14/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Staff are not sufficiently trained, the following has been concluded: Based on a review of a random sample of staff records reviewed during the initial investigation visit on February 3, 2023, all applicable training was found to have been adequately received and documented. A limited number of shifts are covered by Registry staff with potentially less knowledge of the facility's residents, however the placement agency is also responsible for ensuring that their provided staff have received the required training. Therefore, the allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was reviewed and left to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/31/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230131162326

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: 20DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Erin Rehbein, Director of Marketing
Stephanie Garcia Rios, Wellness Director
Rogelio Martinez, Maintenance Director
Michelle Goodney, Administrator		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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1/ Staff are restraining residents while in care.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Michelle Goodney after explaining the purpose of the visit and listing the allegations.

An initial visit was conducted on February 3, 2023. A tour of the physical plant was conducted with the administrator, and temperature measurements were taken. A sample of staff training records were reviewed. Staff schedules reviewed. Previous temperature measurements were taken during facility visits on January 4 and January 17, 2023.

Seven additional staff interviews were conducted during an investigation visit for complaint reference #22-AS-20221228101134 on March 6, 2023.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20230131162326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT BEACH MEMORY CARE
FACILITY NUMBER: 306005154
VISIT DATE: 04/14/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A

LPA additionally reviewed two Special Incident Reports submitted by the facility to the Department on March 17, 2023 and March 21, 2023 regarding two fall incidents that occurred during the use of the recliner seats with the legs in the upward position.

A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed.

Regarding the allegation that Staff are restraining residents while in care, the following has been concluded: Based on interviews conducted and observations made during three separate tours of the physical plant, recliners were confirmed to have been in use in the upward position during each of the visits. Even though residents did not appear to exhibit signs of distress at the time, the Department later received two incident reports linked to fall incidents that occurred while the recliners were up and residents with limited mobility or impaired cognition were not able to exit the seats safely without staff assistance. As a result, the allegation that Staff are restraining residents while in care is deemed to be Substantiated, meaning that the preponderance of evidence standard has been met.

A type B citation is issued regarding the deficiency substantiated during the investigation.

An exit interview was conducted and a copy of this report along with appeal rights were reviewed and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20230131162326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87608(a)(2)
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The California Code of Regulations Section 87608(a)(2) states that: "Postural supports shall be fastened or tied in a manner that permits quick release by the resident." This requirement is not met as evidenced by:
On multiple documented instances, residents were found to be unable to bring (...)
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Licensee to provide in-service training to care staff regarding the safe use of the recliners with an emphasis making sure to not impeded a resident's personal right to ambulate and safely ensuring the residents' ability to exit the recliner if it is put up. Documentation of the training to be provided before POC due date
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(...) the legs of the recliner seat down, contributing to a fall incident. This constitutes a potential risk to the health, safety and personal rights of the individuals 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7