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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005154
Report Date: 05/18/2022
Date Signed: 05/18/2022 03:26:02 PM

Document Has Been Signed on 05/18/2022 03:26 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NEWPORT BEACH MEMORY CAREFACILITY NUMBER:
306005154
ADMINISTRATOR:HADLEY, BRIANFACILITY TYPE:
740
ADDRESS:1000 HALYARDTELEPHONE:
(949) 220-9700
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 42CENSUS: 21DATE:
05/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Chanel SanchezTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 04/12/2022. LPA was greeted and granted entry into the facility by Administrator Chanel Sanchez and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 1569.695(f)(1) pertaining to Emergency Water has been cleared. Licensee obtained emergency water. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87468.2(a)(2) pertaining to Medical Assessments has been cleared. Licensee obtained updated physician reports. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 1569.695(f)(1) pertaining to Evacuation Chairs has been cleared. Licensee obtained evacuation chairs. Licensee has complied with the terms of the POC.

Advisory note dated 04/12/2022 indicated the following item to be addressed:
  • Facility is not screening staff or visitors. LPA was not screened upon entry.



Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of the appeal rights were given at time of visit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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Document Has Been Signed on 05/18/2022 03:26 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/18/2022 at 02:54 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 BEACH MEMORY CARE
FACILITY NUMBER: 306005154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited
CCR
87468.1(a)(2)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by:
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Licensee agrees to screen all who enter the facility and forward proof to LPA by POC due date.
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Based on observation, Licensee is not screening visitors to the facility. Facility was given an advisory on 04/12/2022 to begin screening visitors. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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