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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 10/05/2022
Date Signed: 11/03/2022 04:54:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221003102027
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:
10/05/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Chanel Sanchez, Executive Director
Yvonne Laumasima, staff		TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not provide authorized representative with refund.
INVESTIGATION FINDINGS:
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This report was amended. Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required complaint investigation. LPA arrived at facility, was greeted and granted entry by Chanel Sanchez, Executive Director after explaining the purpose of the visit and detailing the allegation investigated.

LPA requested and obtained the facility census, as well as an admission packet designed for prospective residents including a blank admission agreement which includes a provision regarding the facility refund procedure in the event of a resident's death. Agreement indicates that refund will be issued "within fifteen (15) days after (...) personal property is removed from the facility".

LPA also requested copies of the records kept at the facility for resident 1 (R1). Records were obtained during the visit and include the resident's signed admission agreement. Facility staff is unable to provide any documentation of a processed refund at the time of the visit. CONTINUED ON FORM LIC9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20221003102027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306005154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2022
Section Cited
CCR
87507(f)
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The California Code of Regulations Section 87507(f) regarding Admission Agreements indicates that : "The licensee shall comply with all applicable terms and conditions set forth in the admission agreement(...)"

This requirement is not met as evidenced by:
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Licensee will provide documentation of the submission and effective payment of the refund to Licensing Program Analyst before the Plan of Corrections due date.
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Based on observation, file review and interviews conducted, no refund has been issued in excess of the 15-day agreement upon admission. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221003102027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306005154
VISIT DATE: 10/05/2022
NARRATIVE
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CONTINUED FROM FORM LIC9099

LPA interviewed administrator Chanel Sanchez and Yvonne Laumasima, staff member in charge of facility payroll and accounts payable. Both staff members described the typical procedure for the pro-rating and refunding of fees, however both indicate that the previous administrator did not follow the procedure and no documentation exists. Additionally, the facility is transitioning their administrative service providers. No request for a refund has been submitted to accounts payable or the clearinghouse in charge of issuing the funds at this time.

During the visit, facility staff generated an invoice for the refund and worked towards getting the refund submitted to the appropriate agency.

Based on LPA’s information gathered through staff and witnesses interviews and review of records and staff admission statement that a refund has yet to be issued, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An attached form LIC9099D is generated for the cited deficiency.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3