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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005789
Report Date: 09/09/2025
Date Signed: 09/09/2025 03:36:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/02/2025 and conducted by Evaluator Hanna Gough
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250902095612
FACILITY NAME:ATRIA NEWPORT BEACHFACILITY NUMBER:
306005789
ADMINISTRATOR:KEYS, BRIANFACILITY TYPE:
740
ADDRESS:393 HOSPITAL ROADTELEPHONE:
(949) 631-3555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY:195CENSUS: 164DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brian KeysTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff were unaware of residents Portable Medical Orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned allegation. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Brian Keys and discussed the purpose of the visit.

The investigation into the allegation Staff were unaware of residents Portable Medical Orders revealed the following: Resident #1(R1) was admitted to the facility on December 14, 2023. LPA observed R1s physicians report dated January 6, 2025, stating that there is an advanced directive and Physicians Orders for Life-Sustaining Treatment (POLST) in place for R1. LPA observed R1s functional needs and services plan dated January 16, 2024, stating that there is a POLST on file and that R1s code status is Do Not Resuscitate (DNR). LPA observed R1s face sheet that has emergency contacts and code status as DNR. LPA observed a POLST dated December 12, 2023 that was marked as DNR. LPA observed the POLST to be signed by a physician.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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 3
Control Number 22-AS-20250902095612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 BEACH
FACILITY NUMBER: 306005789
VISIT DATE: 09/09/2025
NARRATIVE
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LPA observed a Directive to Physicians dated March 19, 2008, signed by R1 stating that if R1 at any time is in a terminal condition or should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will in the opinion of R1s attending physician withhold or withdraw treatment that only prolongs the process of dying and is not necessary for R1s comfort or to alleviate pain.

During interviews it was revealed that staff called emergency services twice on August 24, 2025, for R1 due to changes in condition. It was revealed that 3 of 5 staff were present at the time of the incidents. 2 of 5 staff informed LPA that staff were delayed in giving emergency personnel all necessary documentation due to the printer being down. 2 of 5 staff informed LPA that emergency services were given all of the necessary documentation as they were exiting the facility with R1. Staff #3 (S3) informed LPA that emergency services were called again in the evening due to R1 being unresponsive. S3 informed LPA that they started chest compressions until emergency personnel arrived to the facility. S3 informed LPA that emergency personnel informed them that there was a POLST and DNR in place for R1 and S3 stopped compressions once they were made aware of the directives in place. 2 of 5 staff informed LPA that it is the facility policy to provide emergency personnel with necessary documentation upon their arrival and to follow the DNR and POLST directives that are in place. 4 of 5 staff informed LPA that when giving emergency personnel documentation they give the face sheet, insurance documentation, and medication list. Witness #1(W1) informed the Department that they saw staff conducting chest compressions on R1. W1 informed the Department that there was a delay with facility staff giving the necessary documentation upon emergency personnel’s arrival.

Based on observation, interviews, record review and information gathered during the investigation, 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 are being cited on the attached LIC 9099D.

An exit interview was conducted with ED Brian Keys and a copy of this report, LIC9099-D and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250902095612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 BEACH
FACILITY NUMBER: 306005789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/07/2025
Section Cited
CCR
87469(c)(1)
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87469(c)(1)Advanced Directives and Requests Regarding Resuscitative Measures(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel...
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Executive Director stated they will do an audit of all residents to check for POLST documentation, put in emergency folders for emergency personnel, and give an in service to staff by POC due date.
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This requirement is not met as evidence by:
2 of 5 staff confirmed that emergency services were not given necessary documentation until they were leaving the facility with R1. This poses a potential health, safety, or personal rights risks to persons in care.
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Deficiency Dismissed
Type B
10/07/2025
Section Cited
CCR
87468.1(b)(8)
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87468.1(b)(8) Personal Rights of Residents in All Facilities (8) ... Provide medical or nonmedical care to the resident in a manner that... unduly demeans the resident’s dignity...
This requirement is not met as evidence by:
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Executive director stated they will do an in service for staff regarding DNR status of residents and place a DNR list in the medication room for staff access.
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1 of 5 staff performing chest compressions when R1 had a DNR in place and did not stop until emergency personnel informed them of the DNR. This poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3