306005449-2-17-2023-22-AS-KLYN-CP5T5K-20230217132540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:26:23 PM

Document Has Been Signed on 02/17/2023 01:26 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 PLAZA		FACILITY NUMBER:	306005449
ADMINISTRATOR:	GONZALEZ, JOHANNA		FACILITY TYPE:	740
ADDRESS:	1455 SUPERIOR AVE		TELEPHONE:	(949) 645-6833
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	160	CENSUS:	DATE:	02/17/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Adam Alvarado		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Maintenance Director Adam Alvarado and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. The purpose of today’s visit is to follow up on an investigation conducted by the Department. The investigation conducted revealed the following: Resident 1 (R1) was admitted into the facility on 08/08/2022 and was assessed to be independent of all activities of daily living except for medication management. Resident had been living independently prior to moving to facility but had difficulties with medication management resulting in the resident’s placement at facility by R1’s family. R1’s pre-appraisal dated 08/02/2022 indicated R1 was independent of care and had a diagnoses of Parkinson’s Disease. R1 had a noted history of hallucinations due to inconsistency of taking their Parkinson’s medication. Per the appraisal, when R1 is taking prescribed Parkinson’s medication as prescribed, R1 is considered mentally stable with no hallucinations. At the time of admission, R1 was believed to have been stabilized with no current hallucinations. R1’s physician report dated 08/04/2022 confirms the history of Parkinson’s related hallucinations, depression, and anxiety along with a diagnosis of Mild Cognitive Impairment. During the assessment process, staff spoke with family regarding the depression diagnosis and family stated it was mostly historical as R1 had suffered from depression since early childhood. R1 was not exhibiting any signs of distress through the admission process. On 08/14/2022, R1 verbalized to staff that they wanted to disappear. Staff believed the statement was reflective of the resident being new at the facility and adjusting to the new surroundings. R1 was observed during the week periodically coming into the dining room to eat and staff reported no concerns had been observed. Resident had been eating in their room, per the resident’s preference, when not in dining room. Staff had seen no other concerns with the resident. On 08/16/2022, Staff 1 (S1) reported they went to R1’s room CONTINUED ON LIC 809C DATED 02/17/2023

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 PLAZA	FACILITY NUMBER: 306005449
	VISIT DATE: 02/17/2023

NARRATIVE

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around 7:45 AM to check on the resident as resident had not come down for breakfast. Upon entry, S1 observed R1 lying on the loveseat in their room with a purple bag wrapped around R1’s head. R1 was cold to the touch and appeared to be unresponsive. 911 was called and Newport Beach Police responded. R1 was declared deceased and the Deputy Coroner arrived to examine the body. The Coroner determined there was no other trauma present on the rest of the resident’s body. R1 had been residing in the assisted living and facility checks were not required, per facility protocol, due to R1 being independent of activities of daily living. However, all staff interviewed confirm resident was being frequently checked on as the resident was acclimating to living at the facility. Interviews conducted reported R1 was last checked on at approximately 8 PM on 08/15/2022 at which time staff did not suspect any indication of suicidal ideation. R1’s death certificate was issued by Orange County Coroner’s office with an immediate cause of death listed as Asphyxiation with plastic bag over head.

Based on the investigation, there is no evidence to determine lack of care and supervision resulted in R1’s death. Therefore, the allegation was determined to be unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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