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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006401
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:48:13 PM

Document Has Been Signed on 02/21/2025 03:48 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:CLEARWATER NEWPORT BEACHFACILITY NUMBER:
306006401
ADMINISTRATOR/
DIRECTOR:		JOHNSTON, ROBERTFACILITY TYPE:
740
ADDRESS:101 BAYVIEW PLACETELEPHONE:
(949) 942-6391
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 120CENSUS: 57DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Maria Rossi, Vice President of Operations TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Alvaro Ramirez Jr. and Hanna Gough made an unannounced visit for the purpose of conducting the required annual inspection. Upon entry LPAs were greeted by the receptionist and explained the purpose of the visit. LPAs met with Vice President of Operations (VPO) Maria Rossi.

During the inspection, LPAs and VPO conducted a tour of the inside and outside of the facility, common areas, resident rooms, and observed the following:

The facility consists of a three story building, with memory care being on the second floor. The building has common areas which include, a dining room, multiple activity rooms, multiple outside areas with shaded seating, and a wellness center. Resident rooms were inspected and all were observed to have the required components and furnishings. LPAs observed all resident beds had clean linens and blankets. Signal system was tested and observed to be operational with a seven minute response time. The delayed egress in the memory care unit was tested by LPAs and found to be operational. Bathrooms were observed to have functioning faucets and toilets with slip mats, textured shower floors, and grab bars. Water temperature tested between 109.2-119.4 degrees Fahrenheit.

LPAs observed that the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations with a clean and operational kitchen. LPAs observed the emergency food and water supply. LPAs reviewed the reports for the fire and sprinkler system dated February 4, 2025 and were found to be operational. LPAs reviewed the carbon monoxide reports dated January 8, 2025 and were found to be operational. The last fire drill was conducted on February 10, 2025. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in a medication cart located within the medication rooms. The medication rooms are located on the second and third floor. LPAs reviewed centrally stored medication for residents and did not observe any discrepancies. (Cont. LIC809-C)
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CLEARWATER NEWPORT BEACH
FACILITY NUMBER: 306006401
VISIT DATE: 02/21/2025
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LPAs reviewed five resident files and four staff files, no discrepancies were observed.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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