<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005789
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:49:45 PM

Document Has Been Signed on 12/12/2024 12:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ATRIA NEWPORT BEACHFACILITY NUMBER:
306005789
ADMINISTRATOR/
DIRECTOR:		KEYS, BRIANFACILITY TYPE:
740
ADDRESS:393 HOSPITAL ROADTELEPHONE:
(949) 631-3555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 195CENSUS: 158DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Brian Keys, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 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
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on an incident report submitted by the facility on December 10, 2024. Per the incident report submitted and reviewed, resident R1 left the community unassisted on December 10, 2024 at approximately 11:58am. R1's absence was noticed at approximately 12:25pm. 911 was called and a search performed which resulted in the resident being located and brought back unharmed to the facility.

During the present visit, LPA requested R1's physician report and individual needs assessment which confirmed R1 resides in the Memory Care unit of the facility and is assessed to not be able to leave the facility unsupervised after following an unspecified staff member out of the secure perimeter of the memory care unit. Based on the incident report and records reviewed, it is thus confirmed that no supervision was provided temporarily until the resident was found approximately two and a half hours later.

Since the incident, R1 has been provided with 72-hours of private caregiver supervision. All facility staff has received an updated in-service training on elopement prevention, documentation of which was obtained during the visit.

Based on the evidence gathered during today's visit, a type A deficiency is being cited. An exit interview was conducted and a copy of the present report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/12/2024 12:49 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/12/2024 at 12:21 PM
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
80078(a)

1
2
3
4
5
6
7
Per CCR Section 80078(a) regarding the Responsibility for Providing Care and Supervision: "(a) The licensee shall provide care and supervision as necessary to meet the client's needs".
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Since the incident, resident R1 has been receiving 72 hours of private caregiver supervision. Additionally, a facility-wide in-service training on Elopement prevention has been conducyed on December 11, 2024.
8
9
10
11
12
13
14
Based on interviews and records reviewed, resident R1 was assessed to be unable to leave the premises unassisted and was unsupervised for approximately 2.5 hours outside the facility. This constitutes an immediate rsisk to the health, safety and personal rights of 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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2