306006401-2-12-2024-22-AS-DLMN-D2DRXS-20240212122514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006401
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:25:58 PM

Document Has Been Signed on 02/12/2024 12:25 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CLEARWATER NEWPORT BEACH		FACILITY NUMBER:	306006401
ADMINISTRATOR:	JOHNSTON, ROBERT		FACILITY TYPE:	740
ADDRESS:	101 BAYVIEW PLACE		TELEPHONE:	(949) 942-6391
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY:	120	CENSUS:	DATE:	02/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robert Johnston - Administrator		TIME COMPLETED:	12:40 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	Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Diana Navarro, Vice President of Operations and brought to the office of the Administrator Robert Johnston. An application to operate a Residential Care Facility for the ElderLY (RCFE) for (120) capacity, (0) ambulatory, (112) non-ambulatory, and (8) bedridden residents was received by CCL on 8/7/2023. Structure - The four-story facility houses Assisted Living (AL) and Memory Care (MC) apartments. The lower level houses the parking garage, 2 common bathrooms, Activities Room, Theater, Salon, Exercise Room, commercial laundry room and Employee offices. The 1st floor houses 21 AL apartments, 2 common bathrooms, Living Room, Club Room, Private Dining Room, Outdoor Patio, Courtyard, Cafe, Kitchen, Common Dining Room, laundry room, loading dock, Reception and employee offices. The 2nd floor houses 9 AL apartments, 31 MC apartments, 1 MC common bathroom, MC Dining Room, MC Living Room, MC Activity Space, MC Salon, 2 MC Patios, AL laundry Room, MC Laundry Room, Chart Room, Med Room, Satellite Kitchen and employee offices. The 3rd floor houses 40 AL apartments, Health Services Office, laundry Room, Chart Room and Med Room. LPA observed the facility to be clean and sanitary. Resident Apartments/Bedrooms/Hot Water - LPA toured 3 model apartments. All apartments have private bathrooms. LPA measured hot water in rooms on each floor. Hot water measured was observed to be between 105 and 120 degrees Fahrenheit. LPA observed all windows were screened. Medications, Files, First-Aid Kit will all be stored in Chart Rooms and Med Rooms. Activities - The facility has an exercise room, a theater, salons, as well as activity rooms equipped with board games, art supplies and more for resident use.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLEARWATER NEWPORT BEACH	FACILITY NUMBER: 306006401
	VISIT DATE: 02/12/2024

NARRATIVE

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Kitchen/Food Service/Emergency Food & Water/Toxins - There is a 2-day supply perishable food and a 7-day supply of non-perishable food on hand. Emergency food supply is located in the kitchen. Emergency water is located in 55-gallon drums. There are 3 on each floor, LPA observed a walk-in refrigerator, a walk-in freezer, a walk-in pantry and noted the kitchen has working appliances and can be locked from all entrances. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the kitchen and laundry rooms. LPA noted the toxins stored in the kitchen are stored separate from food and food-handling items.

The Fire Clearance, including the smoke/carbon monoxide detectors/sprinkler system was approved by a fire inspector of Newport Beach Fire Department on 12/21/2023. All fire extinguishers are fully charged. The service tags indicates they were last serviced on 7/28/2023.

Emergency Phone Numbers, Exit Plan, Activity Calendar & Menu are all posted and available for review.

Component III was reviewed and provided via PDF. Comp III provides a general overview of how to maintain compliance in accordance with regulations.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report and Component III presentation were provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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