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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:27:38 PM


Document Has Been Signed on 07/21/2022 02:27 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: 94DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Johanna GonzalezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports received by Community Care Licensing. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez.

Incident report dated 07/18/2022 indicated Resident 1 (R1) was found right outside the facility gate near the gas station neighboring the facility. R1 was redirected back into the facility with no adverse effects. Resident is a new admit to the facility and had been living at the facility for only a few days. Resident moved into the facility after living independently in own home and driving. Facility investigation revealed that the resident had come to the front desk wanting to leave but was redirected. R1 went into the movie theater to relax. Reception went to check on the resident a few moments later and the resident was not there. Reception put out a page to staff to check in room and reception went outside where the resident was observed. R1 may have gone out a back door which is unlocked and opens into the front of facility where R1 was found. Facility put a one on one companion with resident until results of a urinalysis come back. Physician report dated 07/13/2022 indicates R1 has a diagnosis of Dementia and is unable to leave the facility unassisted.

Incident report dated 07/07/2022 indicated R2 was sent out to Hoag Hospital after verbalizing suicidal ideations. Resident returned to the facility with no medication changes and cleared by physician. Resident has not had any prior suicidal ideations or since then and states the resident was just frustrated that day. Physician report dated 04/22/2022 indicates a diagnosis of Mild Cognitive Impairment and no diagnosis of any mental health issues.
During the visit, LPA met with both residents who verbalized satisfaction with the facility and felt safe at the facility. Both appeared clean and well taken care of.
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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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