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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005449
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:42:35 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20221006125126
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: DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Johanna Gonzales, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1/Facility staff mismanaged resident's medications (resident was overmedicated).
3/ Facility did not give resident a 30 day notice.
4/ Facility staff did not ensure that resident was adequately hydrated.
8/ Facility bathrooms do not provide a safe environment for residents in care (no support commode frames, grab bars).
9/ Facility bathrooms did not have supplies (soap, paper towels, toilet paper).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Johanna Gonzalez after explaining the purpose of the visit.

LPA conducted an initial facility visit on October 11, 2022. LPA interviewed the Director of Resident Services as well as attempted to interview resident R1. Resident records were requested, obtained and reviewed during the visit. Incident reports regarding resident R1 and submitted by the facility to the Department were reviewed. A follow-up facility visit was conducted on February 27, 2023. Additional records reviewed. Executive Director and Memory Care Director interviewed. Resident was transferred to Newport Beach Senior Care III (facility #306004302) and passed away there on November 3, 2022. Admission records and hospice records were also reviewed and additional interviews conducted by LPA.

CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20221006125126

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: DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Johanna Gonzales, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
2/ Facility staff did not keep accurate records on resident(s).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Johanna Gonzalez after explaining the purpose of the visit.

LPA conducted an initial facility visit on October 11, 2022. LPA interviewed the Director of Resident Services as well as attempted to interview resident R1. Resident records were requested, obtained and reviewed during the visit. Incident reports regarding resident R1 and submitted by the facility to the Department were reviewed. A follow-up facility visit was conducted on February 27, 2023. Additional records reviewed. Executive Director and Memory Care Director interviewed. Resident was transferred to Newport Beach Senior Care III (facility #306004302) and passed away there on November 3, 2022. Admission records and hospice records were also reviewed and additional interviews conducted by LPA.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20221006125126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA NEWPORT PLAZA
FACILITY NUMBER: 306005449
VISIT DATE: 03/02/2023
NARRATIVE
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32
CONTINUED FROM FORM LIC9099-A

Regarding the allegation that Facility staff did not keep accurate records on resident(s), the following was concluded: LPA obtained records initially transmitted to the family of resident R1 by facility staff that were shown to include unrelated documents pertaining to resident R2 and R3 that had been included erroneously. The allegation is therefore deemed to be Substantiated, meaning the preponderance of evidence standard has been met.

A citation is issued on an attached form LIC9099-D,

An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20221006125126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA NEWPORT PLAZA
FACILITY NUMBER: 306005449
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2023
Section Cited
CCR
87506(c)
1
2
3
4
5
6
7
The California Code of Regulations Section 87506(c) states that: "All information and records obtained from or regarding residents shall be confidential."
This requirement was not met as evidenced by:
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2
3
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5
6
7
Licensee to conduct an audit of existing resident files to ensure confidentiality compliance before the Plan of Correction due date.
8
9
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14
Based on a review of records conducted by LPA, documents pertaining to residents R2 and R3 were erroneously submiited alongside communications with the family of resident R1. This constitutes a potential risk to the health,. safety and personal rights of individuals in care.
8
9
10
11
12
13
14
1
2
3
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5
6
7
1
2
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5
6
7
1
2
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5
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7
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6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221006125126

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: DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Johanna Gonzales, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure that resident was adequately dressed.

Facility did not have sufficient staff to meet the resident's needs.

Facility staff did not assist resident to the restroom.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Johanna Gonzalez after explaining the purpose of the visit.

LPA conducted an initial facility visit on October 11, 2022. LPA interviewed the Director of Resident Services as well as attempted to interview resident R1. Resident records were requested, obtained and reviewed during the visit. Incident reports regarding resident R1 and submitted by the facility to the Department were reviewed. A follow-up facility visit was conducted on February 27, 2023. Additional records reviewed. Executive Director and Memory Care Director interviewed. Resident was transferred to Newport Beach Senior Care III (facility #306004302) and passed away there on November 3, 2022. Admission records and hospice records were also reviewed and additional interviews conducted by LPA.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20221006125126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA NEWPORT PLAZA
FACILITY NUMBER: 306005449
VISIT DATE: 03/02/2023
NARRATIVE
1
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3
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5
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32
CONTINUED FROM FORM LIC9099-A

Regarding the allegation that Facility staff did not ensure that resident was adequately dressed, Facility did not have sufficient staff to meet the resident's needs, Facility staff did not assist resident to the restroom, the following was concluded: Due to the evolution of resident R1's condition, increasing difficulties with mobilization and transfers were documented by the facility in an attempt to demonstrate the need for a higher level of care. However, a majority of interviews conducted, observation led and records reviewed did not corroborate the fact that the facility was ever negligent in providing care and supervision to the resident.

Therefore, the allegations that Facility staff did not ensure that resident was adequately dressed, Facility did not have sufficient staff to meet the resident's needs and that Facility staff did not assist resident to the restroom are deemed to be Unsubstantiated, meaning that although the allegation may have happened or is 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 provided and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20221006125126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA NEWPORT PLAZA
FACILITY NUMBER: 306005449
VISIT DATE: 03/02/2023
NARRATIVE
1
2
3
4
5
6
7
8
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10
11
12
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility staff mismanaged resident's medications (resident was overmedicated), the following was concluded: Based on a review of prescriptions, nursing notes and interviews conducted, it was confirmed that the medication received by resident R1 was based on prescriptions by either the primary care physician or the hospice physician which no prescriptive input from facility staff. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Regarding the allegation that Facility did not give resident a 30 day notice, the following was concluded: Multiple care conferences were initiated by facility staff to inform resident R1's family that the resident's condition had evolved to become incompatible with the care and supervision being provided at the facility. However, the resident's transfer to a different facility was consensual and no orders for an eviction were issued due to no eviction being initiated. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Regarding the allegation that Facility staff did not ensure that resident was adequately hydrated, records of medical examination dated October 4, 2022 by the hospice physician were obtained and reviewed during the investigation. Report states clearly that no signs and symptoms of dehydration were present in resident R1. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Regarding the allegation that Facility bathrooms do not provide a safe environment for residents in care (no support commode frames, grab bars) and that Facility bathrooms did not have supplies (soap, paper towels, toilet paper), the following was concluded: During facility visits conducted on October 11, 2022 and February 27, 2023, LPA conducted a tour of several units in the memory care wing of the facility and observed both the presence of grab bars and non-slip surfaces as well as hygiene supplies stored under lock due to the presence of dementia residents. The allegations are therefore found to be unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7