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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:37:42 AM


Document Has Been Signed on 08/16/2022 11:37 AM - 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:
08/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Johanna GonzalezTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez.

At 8:05 AM, LPA received a voicemail from Administrator for a return call. LPA did not respond as was en route to the facility. When LPA arrived there were multiple law enforcement vehicles outside the facility. LPA entered and was notified that Resident 1 (R1) had been found by staff deceased by self inflicted injury in the resident's room around 7:45 AM. Coroner was on-site as well. Resident 1 admitted into the facility on 08/08/2022 with a diagnosis of Parkinson's Disease complicated with delusions, insomnia, anxiety, depression and anorexia along with Mild Cognitive Impairment. R1 had previously been living in independent living in another location. R1 is independent of any assistance with activities of daily living and was last observed by staff around 630 PM on 08/15/2022. Resident had not been observed to have any behaviors or suicidal ideations since admitting into the facility and was acclimating well and participating in activities and dining. R1's family was actively involved in resident's life and had been visiting the resident since admitting into the facility. LPA attempted to observe the resident's room but room was sealed off per Newport Beach Police Department.

During the visit LPA toured the facility and observed residents participating in activities as well as relaxing in common areas. No health or safety violations noted during today's visit.


Based on the observations made during today's visit, no violations noted. 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: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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