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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005789
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:56:07 AM


Document Has Been Signed on 02/17/2022 11:56 AM - 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: 69DATE:
02/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:George GonzalezTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report/ SOC 341 dated 02/07/2022. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

Incident report indicated Resident 1 (R1) was touched inappropriately on the hand by R2. Facility investigated the incident as well as contacted Newport Beach Police. R1 is noted to have no injuries.

During the visit, LPAs toured the facility as well as interviewed R1 and R2. Both residents appeared clean, happy, and well taken care of. R1 verbalized satisfaction with the facility. Per physician report dated 10/21/2021, R2 is diagnosed with Dementia. No health and safety concerns noted.








No deficiencies noted during today's visit. An exit interview was conducted 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: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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