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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005789
Report Date: 04/26/2022
Date Signed: 04/26/2022 12:11:13 PM

Document Has Been Signed on 04/26/2022 12:11 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 BEACHFACILITY NUMBER:
306005789
ADMINISTRATOR:REDMAN, DORIFACILITY TYPE:
740
ADDRESS:393 HOSPITAL ROADTELEPHONE:
(949) 631-3555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 195CENSUS: 77DATE:
04/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:George GonzalezTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint investigation 22-AS-20211122170311. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, it was revealed that Resident 1 (R1) had a ring video camera installed in the resident's room by family. Interview with facility management confirmed the facility staff was aware of the video camera. LPA toured the resident's room during the investigation on 11/24/2021 and did not observe any signage noting that video recording was occurring.


Based on the observations made during the complaint investigation, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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Document Has Been Signed on 04/26/2022 12:11 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 04/26/2022 at 08:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA NEWPORT BEACH
FACILITY NUMBER: 306005789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
87468.2(a)(2)

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In addition to the rights listed in Section 87468.1.., residents in privately operated residential facilities... shall have the following rights: To have a reasonable level of personal privacy in accommodations... personal care assistance, visits, communication, telephone conversations, internet,. This requirement is not being met as evidenced by:
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Licensee posted a sign alerting of video surveillance in resident's room. CLEARED DURING VISIT.
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Based on interview and observation, Licensee failed to ensure R1 was provided a reasonable level of privacy. R1's family posted a ring video camera in R1's room. There was no signage alerting that video taping was occurring. This poses a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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