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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 08/01/2023
Date Signed: 08/01/2023 10:51:37 AM

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
02/23/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220223160724
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: 18DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Michele GoodneyTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is refusing to disclose information regarding the incident
Facility did not report a fall that occurred to a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Director Michele Goodney and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegations that facility is refusing to disclose information regarding the incident and facility did not report a fall that occurred to a resident, the investigation revealed the following: On 10/06/2021, Resident 1 (R1) was observed to have an abrasion on right eye and complained of hip and leg pain. Facility notified responsible party of bruise and hip pain and physician ordered mobile X-ray per responsible party. Results of X-ray on 10/07/2021 indicated a right hip fracture and resident was sent out to Hoag Hospital. Facility staff deny witnessing any fall and facility states being unsure how the injury occurred. Facility provided an incident report to the department on 10/13/2021. Facility documentation dated 10/06/2021 indicated it was unknown if a fall had occurred and that responsible party and physician CONT ON LIC 9099C DATED 08/01/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 2
Control Number 22-AS-20220223160724
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: 08/01/2023
NARRATIVE
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were notified of the incident at 8:30 AM on 10/06/2021. Responsible party confirms being notified of the resident's pain and bruising. Facility indicated resident was equipped with a clip alarm as well as a lowered bed and was observed frequently. Due to conflicting information, the department is unable to corroborate the allegations. Therefore, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided and left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
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