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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:19:21 PM

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:ATRIA NEWPORT PLAZAFACILITY NUMBER:
306005449
ADMINISTRATOR:GONZALEZ, JOHANNAFACILITY TYPE:
740
ADDRESS:1455 SUPERIOR AVETELEPHONE:
(949) 645-6833
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:160CENSUS: 101DATE:
06/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Johanna GonzalezTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing (CCL)). LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez.

Incident report dated 05/16/2021 indicated Resident 1 (R1) became aggressive with staff and 911 was called. R1 refused to go out and psych evaluation requested. A one on one companion was placed with R1. R1 was previously evaluated ay Chapman Global Medical Center. Physician report dated 05/01/2021 indicated a diagnosis of Dementia with Psychosis and physician notes indicate R1 was suicidal. R1 moved out of the community on 06/15/2021.

Death report dated 05/10/2021 indicated R2 was discovered on the floor unresponsive and without vital signs. R2 declared deceased by paramedics. Per physician report dated 04/15/2019, R2 is diabetic. R2 was prescribed Carvedilol for Hypertension, Furosemide for Congestive Heart Failure, and Eliquis as a blood thinner. Per facility, autopsy not performed as it was not requested by family.


No citations noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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