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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004302
Report Date: 06/05/2025
Date Signed: 06/05/2025 05:10:41 PM

Document Has Been Signed on 06/05/2025 05:10 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:NEWPORT SENIOR LIVING IIIFACILITY NUMBER:
306004302
ADMINISTRATOR/
DIRECTOR:		BRUCE WINSTEADFACILITY TYPE:
740
ADDRESS:2412 HOLLY LANETELEPHONE:
(714) 351-7800
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 6CENSUS: 5DATE:
06/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Aministrator - Deanna LandonTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On June 5, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility to conduct an unannounced required 1-Year annual visit using the CARE Inspection Tool. LPA announced self and stated the purpose of the visit to Caregiver (CG) Yuriria Rebollar and was granted entry. Administrator (AD) Deana “Chris” Landon was contacted by telephone, arrived at the facility a short time later, and was present throughout the inspection. Administrator certificate for Deana Landon expires on December 27, 2025.
There are five residents on census. Two residents on Hospice and two residents with dementia currently living at the facility. During today’s visit, five residents and six staff are present. LPA obtained copies of pertinent documents for clients and staff, including facility records: residents/staff rosters, Personnel Record (LIC500), resident and staff records.

The facility is a two-story home licensed for 6 non-ambulatory residents and has a Hospice waiver for 5. There are 6 resident bedrooms, 1 caregiver bedroom located upstairs, a living room area, a kitchen, a dining room area, and attached two car garage. There are 7 bathrooms, one located inside each bedroom.

Around 8:45am, LPA conducted a tour of the facility with AD Landon and the following was observed:
Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 110.3 degrees F. and 115.7 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit.
Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: NEWPORT SENIOR LIVING III
FACILITY NUMBER: 306004302
VISIT DATE: 06/05/2025
NARRATIVE
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Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen was inspected and found clean and sanitary. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed knives and sharps locked in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to residents in care. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gate is self-latching and operational. During tour, LPA observed Resident #1(R1), Resident #4 (R4), and Resident #5 (R5) beds all have 1/2 bed rails attached. Licensee stated she did not have orders for the three bed rails and did not know a physician's order was required for 1/2 bed rails. LPA also observed, scissors unlocked/unsecured in Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3) dresser drawers, desk, and shelf. (See LIC809-D attached)

Carbon monoxide/smoke detectors in common areas and bedrooms are operational. The facility’s last fire drill was conducted on March 16, 2025. Emergency food and water supply observed in the garage. First aid kit had all the required elements. Two fire extinguishers are fully charged with a service date of May 5, 2025. A working telephone (714-351-7800) remains available, and the facility has a device that can be used for video teleconference purposes. Liability Insurance is effective February 1, 2025, through February 1, 2026.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), five (5) staff files (S1-S5), and conducted three (3) staff interviews, and four (4) resident interviews. Residents’ medication was found locked, and a review of the Medication and Medication Administration Record (MAR) was conducted.

Based on today’s observations, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with administrator, Deana Landon and a copy of this report LIC809, 809-C, LIC809-D, LIC811, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 05:10 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/05/2025 at 12:16 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: NEWPORT SENIOR LIVING III
FACILITY NUMBER: 306004302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 05:10 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/05/2025 at 04:15 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: NEWPORT SENIOR LIVING III
FACILITY NUMBER: 306004302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on oberservation, record review, and interview, the licensee did not comply with the section cited above in three out of six resident beds, which poses an immediate health and safety risk to persons in care. LPA observed Resident #1(R1), Resident #4 (R4), and Resident #5 (R5) beds all have 1/2 bedrails attached. Licensee stated she did not have orders for the three bedrails and did not know a physician's order was required for 1/2 bedrails.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee agrees to obtain an order from residents physician's for 1/2 bedrail by POC due date. Bedrail orders to be emailed to CCL along with LIC 9098 to verify POC completion.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on oberservation and interview, the licensee did not comply with the section cited above in three out of six resident bedrooms, which poses an immediate health and safety risk to persons in care. LPA observed scissors unlocked/unsecured in Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3) dresser drawers, desk, and shelf. Resident #1 is diagnosed with dementia.
POC Due Date: 06/06/2025
Plan of Correction
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LPA observered Administrator remove all sharps and lock them in secured sharps drawer during inspection. Licensee will ensure all sharps are locked away/secured at all times, effective immediately. Licensee stated they will review regulations and re-train staff on sharps and safe storage. Licensee stated they will email LPA the content covered in the training, training attendees and the date and time of training by 5pm on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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