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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005449
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:20:56 PM


Document Has Been Signed on 05/18/2022 02:20 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: 90DATE:
05/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Johanna GonzalezTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident reports/ SOC 341 received by Community Care Licensing. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez.

Incident report dated 05/13/2022 indicated that a private aid reported smoke coming from Resident 1's (R1) room. Code red initiated and maintenance responded. R1's microwave was on fire. Maintenance cleared the fire with a fire extinguisher. No injuries noted on R1. Resident to be re-assessed and microwave was removed. R1's physician report dated 03/19/2019 does not indicate any cognitive decline and resident is able to manage own medications.

Incident report/ SOC 341 dated 05/16/2022 indicated R2 had entered R3's room uninvited. R3 called out for help and when staff responded R3 was observed hitting R2 with a clothes hanger. R2 was redirected out of the room and noted to have redness on the hand with no open injury. Residents do not recall the incident. R2 was sent for a urinalysis with results pending. Both residents reside in the memory care unit. During the visit, LPA toured the memory care unit and observed both residents who appeared safe and well taken care of.




No deficiencies noted during today's visit 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: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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