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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005154
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:42:49 AM


Document Has Been Signed on 07/28/2022 11:42 AM - 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: 24DATE:
07/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Alex GutierrezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility by Wellness Director Alex Gutierrez and explained the reason for the visit.

During the visit, LPA toured the facility and observed the following: Facility is following covid screening guidelines and LPA observed the screening/ sanitizing station. Residents were observed relaxing in the common areas of the facility and appeared safe and well taken care of.

Facility had two covid cases starting on 07/15/2022. Cases were not reported to Licensing or Public Health and department learned of cases through an outside source. Cases were reported to Licensing on 07/21/2022 after LPA made contact with facility.




LPA consulted with Wellness Director regarding the importance of all staff wearing masks at all times per department guidance.





Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
Exit interview conducted and a copy of the appeal rights were given at time of visit.




SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2022 11:42 AM - 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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following: Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents.., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Based on interviews conducted, Licensee failed to ensure covid cases were reported to Licensing or Public Health. This poses an immediate health and safety risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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