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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:37:40 PM


Document Has Been Signed on 09/06/2022 02:37 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
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: 89DATE:
09/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Johanna GonzalezTIME COMPLETED:
02:54 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 08/26/2022. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez.

Incident report dated 08/25/2022 indicated Resident 1 (R1) advised home health nurse that the resident had been touched inappropriately. 911 was called and Newport Beach Police responded and took a report. R1 indicated that it was a male resident who followed the resident to the resident's room. R1 states telling the male resident to stop, which the resident did, and left the room. Facility conducted an investigation but were unable to determine who the male resident might have been due to a lack of information provided by R1. R1 was put on escorting for two weeks to ensure nobody was following the resident. During the visit, LPA spoke with R1 who verbalized no concern after the situation as well as feeling safe in the community. Per physician report dated 03/26/2021, R1 is fairly independent with facility providing medication management only.

No further action required.



No deficiencies noted during today's visit. Exit interview 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: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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