306005789-2-15-2024-22-AS-AORZ-D2R2ZM-20240223165031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005789
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:10:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/25/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220425101715

FACILITY NAME:	ATRIA NEWPORT BEACH		FACILITY NUMBER:	306005789
ADMINISTRATOR:	REDMAN, DORI		FACILITY TYPE:	740
ADDRESS:	393 HOSPITAL ROAD		TELEPHONE:	(949) 631-3555
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	195	CENSUS: 134	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brian Keys		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff not properly trained on caregiver duties

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to the facility to deliver findings on the above allegation. LPA Lyman was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as staff training records. Regarding the allegation that staff not properly trained on caregiver duties, the investigation revealed the following: Review of staff training records indicated one out of three staff did not have required training. Staff 1 (S1) has 12.5 out of 20 hours of annual training and 4 out of 8 hours of Dementia training. Based on Records reviewed, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 5

Control Number 22-AS-20220425101715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BEACH	FACILITY NUMBER: 306005789
	VISIT DATE: 02/15/2024

NARRATIVE

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Staff 1 (S1) does not have required annual training. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.

*This is an amended report to be deleted in the system. The continuation page was formatted onto one page at delivery and this page did not delete due to a system error.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/25/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220425101715

FACILITY NAME:	ATRIA NEWPORT BEACH		FACILITY NUMBER:	306005789
ADMINISTRATOR:	REDMAN, DORI		FACILITY TYPE:	740
ADDRESS:	393 HOSPITAL ROAD		TELEPHONE:	(949) 631-3555
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	195	CENSUS: 134	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brian Keys		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff are not meeting resident's needs
Facility staff are sleeping on resident's couch
Medication is not properly administered

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to the facility to deliver findings on the above allegations. LPA Lyman was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as pendant response times and termination paperwork. Regarding the allegations that facility staff are not meeting resident's needs, facility staff are sleeping on resident's couch and medication is not properly administered, the investigation revealed the following: On 02/22/2022, Staff 1 (S1) was terminated for sleeping in Resident 1's (R1) room. Facility provided documentation of termination. Review of Resident 1's (R1) medication administration record (MAR) indicates medication was being administered per physician order. Missed medications are noted on the MAR. LPA observed R1's medications on-site during the investigation and all prescribed were present. Facility administrator at time of complaint initiation indicated a delay with the fentanyl patch one time due to process of obtaining a new order. Five out of five staff deny CONTINUED ON LIC 9099C DATED 02/15/2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20220425101715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BEACH	FACILITY NUMBER: 306005789
	VISIT DATE: 02/15/2024

NARRATIVE

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any knowledge of missing medications. Five out of five staff indicate R1's responsible party would refuse staff entry into the resident's room. Facility utilizes electronic scanning to enter a resident's room as well as to reset a pendant alert. Facility documentation shows facility staff scanned in to check on resident on average 12.02 times a day between 04/01/2022 and 04/25/2022. Pendant alert documentation indicated the resident alerted 4 times in April 2022 and staff responded, on average, within 11 minutes.
Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations 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 provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20220425101715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BEACH	FACILITY NUMBER: 306005789
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/29/2024 Section Cited CCR 87412(c)	1 2 3 4 5 6 7	Licensees shall maintain in the personnel records verification of required staff training and orientation. This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide a statement of understanding regarding the regulation and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review, Licensee failed to ensure verification of staff records are in the file. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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