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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:51:36 PM


Document Has Been Signed on 02/02/2023 01:51 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: 102DATE:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Johanna GonzalezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management visit to follow up on an incident report received by Community Care Licensing on 01/30/2023. LPA identified herself and discussed the purpose of the visit with Executive Director (ED) Johanna Gonzalez.

Incident report dated 01/27/2023 indicated that on 1/22/2023 at 4:00 PM, MedTech was on her way to give medication to Resident 1 (R1) when she found out that R1 wasn't inside R1's room. Later MedTech was informed that R1's son, took R1 to ER for leg pain...R1's son informed community on 1/26/2023 that R1 sustained a fracture on pelvis and will be staying a few months in a Skilled Nursing Facility.

LPA Martinez reviewed R1's file, reviewed and obtained copies of Guest Sign In sheet for 01/22/2023; and R1's MAR for 01/2023. ED Gonzalez is unable to state when R1 was picked up by son. R1's sons name is not found on Sign in sheet for 01/22/2023. MAR shows R1 was given AM and afternoon medication on 01/22/2023. Also provided was a copy of Meal Attendance Report that shows R1 ask for Tray service for breakfast and lunch. R1's son picked up R1's belongings on 1/31/2023 and indicated R1 will not be returning to the facility.

Facility to gather detailed information on incident and forward to LPA Martinez by close of business day of 2/6/2023. Further follow up is needed. LPA Martinez will return at a later date to continue follow up on this incident. No deficiencies cited at this time.

Exit interview conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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