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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006500
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:26:34 PM

Document Has Been Signed on 11/26/2024 12:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NEWPORT BEACH SENIOR VILLAFACILITY NUMBER:
306006500
ADMINISTRATOR/
DIRECTOR:		LANDON, DEANNAFACILITY TYPE:
740
ADDRESS:425 RIVERSIDE AVENUETELEPHONE:
(714) 322-1910
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Ali Naghibi, Prospective licensee
Deanna Landon, Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPA was greeted and granted entry by Ali Naghibi, prospective licensee and Deanna Landon, current administrator

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on January 24, 2024 for a capacity of six non-ambulatory residents. This is a application for change of ownership with residents in place. Five residents are currently admitted to the facility. Current hospice waiver for the present licensed location is for a capacity of four. Applicant has requested a hospice waiver for a capacity of six along with the present licensing application.

LPA accompanied by applicant toured the physical plant. The facility is a one-level home with two central patios leading to an alley, as well as an attached two-car garage. There are six private bedrooms all equipped with private en-suite bathrooms. An additional room is assigned to be a staff room and is locked and inaccessible to residents. Necessary components of furnishing for all six bedrooms are observed to be present alongside an adequate supply of linen and bedsheets. Faucets used for personal hygiene are verified to be operational. Water temperature measured in three bathrooms throughout the property at 105.4F, 112F and 113.5F. Grab bars and slip mats are in place in all six bathrooms. Common living spaces are present and furnished as required. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present.

Kitchen equipment is present and operating as required. Sharp items are stored in a drawer secure by a magnetic lock. Cleaning supplies are secured in the attached garage. A secure cabinet is also present in the kitchen. A sufficient supply of perishable and non-perishable food is present in the kitchen's refrigerator, freezer and pantry which are supplemented by a freezer/refrigerator combined with a freezer and additional pantry in the garage. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT BEACH SENIOR VILLA
FACILITY NUMBER: 306006500
VISIT DATE: 11/26/2024
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CONTINUED FROM FORM LIC809
The centrally stored medication storage is located in a secure cabinet where the first aid kit is also observed to be present and complete. The laundry area is located in a separate room with a glass door. Laundry supplies are stored in a locked cabinet. Sound alarms are present on the ways of egress and verified to be in operation during the walk-through.

The fire clearance has been obtained on May 3, 2024 and provided to the Department before the pre-licensing visit. All bedrooms are cleared for non-ambulatory residents. There are no identified bedridden rooms on the fire clearance. Smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. Fire extinguishers present on the premises are observed to be charged and maintained in 2024. Proof of liability insurance coverage provided for the present licensed location and will be transferred once licensed. Quote have been requested and obtained ahead of the present visit. Telephone service is present. Facility staff is using a tablet for residents needing online access.

Current staff will remained employed with the prospective licensee. A total of 11 current staff files were reviewed and found to include all necessary components including health screenings, background clearance and association to the present licensed location, training records along with first aid/CPR training.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and multiple shaded areas are present in both patios along with an appropriately screened outdoor fireplace. The perimeter gates present on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises and delayed egress/locked perimeters are not in use.

Component III was waived as the prospective licensee has already been acting as the current licensee and operator for other licensed locations. This report was reviewed with facility representative and a copy of this report was emailed to the applicant before the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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