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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005154
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:52:37 PM


Document Has Been Signed on 03/06/2023 04:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
306005154
ADMINISTRATOR:HADLEY, BRIANFACILITY TYPE:
740
ADDRESS:1000 HALYARDTELEPHONE:
(949) 220-9700
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:42CENSUS: 20DATE:
03/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Michele Goodney, AdministratorTIME COMPLETED:
02:00 PM
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of delivering an amended form LIC9099 for a complaint investigation 22-AS-20230131162326 conducted on February 3, 2023. LPA was greeted and granted entry by Administrator Michele Goodney.

The original facility visit report was marked as concluded the allegations as unsubstantiated, while the narrative of the report and exit interview conducted considered the allegations as requiring further investigation. The report was amended to reflect the correct status for the ongoing investigation.

Exit interview conducted and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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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