Inspection Reports for
Newport Nursing and Rehabilitation Center
1555 Superior Ave, Newport Beach, CA 92663, United States, CA, 92663
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
73% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 117
Capacity: 160
Deficiencies: 0
Date: Jan 12, 2026
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements for the Residential Care Facility for the Elderly.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. Observations included clean and well-equipped resident apartments, operational safety equipment, proper medication storage, and complete resident files with current documentation and training.
Report Facts
Licensed capacity: 160
Current census: 117
Hospice waiver capacity: 25
Fire inspection date: Aug 18, 2025
Resident files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator / Executive Director | Present during inspection and assisted with the visit; named in report narrative |
| William Vanegas | Licensing Program Analyst | Conducted the inspection |
| Brandon Lopez | Licensing Program Analyst | Conducted the inspection |
| Armando J Lucero | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
The inspection was conducted due to complaints regarding physical abuse between residents and failure to maintain a safe environment preventing elopement incidents.
Complaint Details
The complaint investigation substantiated that Resident 3 physically assaulted Resident 4 on two occasions causing bleeding and bruising. The facility also failed to prevent Residents 1 and 2 from eloping through an exit door without alarm activation.
Findings
The facility failed to protect residents from physical abuse when Resident 3 punched Resident 4 multiple times causing injuries, and failed to maintain adequate supervision and secure environment to prevent Residents 1 and 2 from eloping through an exit door.
Deficiencies (2)
Failure to protect residents from physical abuse resulting in injuries to Resident 4 caused by Resident 3.
Failure to maintain a safe and secured environment to prevent elopement of Residents 1 and 2.
Report Facts
Date of physical assault incidents: Jul 6, 2025
Date of elopement incident: Jun 20, 2025
Medication dosage: 300
Medication dosage: 10
Pain level: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Observed Resident 4 sitting near medication cart and witnessed first punch incident |
| RN 3 | Registered Nurse | Interviewed Resident 3 after first incident and observed second assault |
| CNA 2 | Certified Nursing Assistant | Reported Resident 3 punched Resident 4 and described incidents |
| CNA 5 | Certified Nursing Assistant | Provided one-to-one care for Resident 3 and witnessed second assault |
| DON | Director of Nursing | Acknowledged findings of abuse and elopement incidents |
| Maintenance Director | Maintenance Director | Reported on exit door alarms and maintenance checks |
| Administrator | Facility Administrator | Acknowledged findings and showed video of elopement incident |
| MHW 2 | Mental Health Worker | Witnessed elopement incident and door banging |
| CNA 1 | Certified Nursing Assistant | Observed Residents 1 and 2 eloping through exit door |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 160
Deficiencies: 0
Date: May 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-02-24 regarding five allegations about resident care and supervision at the facility.
Complaint Details
The complaint involved allegations that staff did not reappraise a resident when his condition changed, failed to provide sufficient notice before changing a resident's care plan, kept a resident isolated in his room, did not provide adequate care to prevent falls, and accepted a resident requiring a higher level of care. The investigation found no preponderance of evidence to substantiate these allegations.
Findings
All five allegations were found to be unsubstantiated after review of resident assessments, staff interviews, and facility tours. The investigation concluded that the facility provided appropriate care and supervision, and residents were not improperly isolated or accepted beyond the facility's capacity.
Report Facts
Capacity: 160
Census: 115
Number of allegations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Facility administrator present and assisted with the visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Sheila Santos | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 160
Deficiencies: 0
Date: May 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-02-24 regarding five allegations about resident care and facility practices.
Complaint Details
The complaint involved allegations that staff did not reappraise a resident when his condition changed, failed to provide sufficient notice before changing services, kept a resident isolated, did not provide adequate care to prevent falls, and accepted a resident requiring a higher level of care. The investigation concluded all allegations were unsubstantiated.
Findings
The investigation found all five allegations unsubstantiated after reviewing resident assessments, staff interviews, and facility tours. Evidence did not support claims of failure to reappraise residents, inadequate notice to authorized persons, resident isolation, inadequate care to prevent falls, or inappropriate resident acceptance.
Report Facts
Capacity: 160
Census: 115
Number of allegations: 5
Date complaint received: Feb 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Facility administrator present and assisted with the visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 111
Capacity: 160
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
The inspection was an unannounced required annual inspection to evaluate compliance with licensing regulations.
Findings
The facility was generally found to be in compliance with regulations, including adequate staff training, proper maintenance of resident rooms, and safety systems. However, one Type B deficiency was cited related to improper management of self-administered medications for a resident.
Deficiencies (1)
Prescription ointments and over-the-counter supplements were observed in the bathroom of a resident assessed to be unable to manage their self-administered medication, posing a potential health, safety, or personal rights risk.
Report Facts
Residents receiving hospice care: 5
Residents in Memory Care unit: 14
Resident rooms: 112
Rooms in Memory Care unit: 12
Hot water measurement locations: 12
Deficiencies cited: 1
Plan of Correction due date: Jan 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Notified of the visit and mentioned in the inspection narrative |
| Karla Arteaga | Community Business Director | Assisted licensing staff during the visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hanna Gough | Licensing Program Analyst | Conducted the inspection |
| Sheila Santos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 111
Capacity: 160
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility generally met regulatory requirements including staff background checks, training, and physical plant safety. One Type B deficiency was cited related to improper storage of prescription ointments and over-the-counter supplements in a resident's bathroom despite the resident being under medication management.
Deficiencies (1)
Prescription ointments and over-the-counter supplements were observed in the bathroom of a resident assessed to be unable to manage their self-administered medication, posing a potential health and safety risk.
Report Facts
Residents receiving hospice care: 5
Residents in Memory Care unit: 14
Resident rooms: 112
Memory Care rooms: 12
Hot water measurement locations: 12
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Notified of the visit and mentioned in the report |
| Karla Arteaga | Community Business Director | Assisted Licensing Program Analysts during the visit |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and signed the report |
| Hanna Gough | Licensing Program Analyst | Conducted the inspection |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, medication administration errors, inadequate implementation of care plans, improper infection control practices, unsafe medication storage and disposal, and unsanitary kitchen conditions. The facility also lacked documentation for Legionella risk assessment and water management.
Deficiencies (13)
Failure to ensure LVN informed physician of change in condition for Resident 598 after neurological assessment.
Resident 301's PHI was displayed on a computer screen in hallway during medication administration, risking privacy violation.
Failure to implement bilateral floor mats for Resident 298 and failure to administer Resident 301's Lidocaine patch as per care plan.
Failure to ensure appropriate Low Air Loss mattress settings and wound care for Residents 598 and 599.
Failure to ensure accident hazards were minimized: gait belt not used for Resident 600 transfers and bilateral floor mats not implemented for Resident 298.
Failure to maintain IV access for Resident 398 by not documenting PICC line catheter length and arm circumference measurements.
Failure to clean CPAP machine and components for Resident 12 as per manufacturer guidelines.
Failure to ensure appropriate pain management for Residents 12 and 599 including administration of pain meds outside ordered parameters and lack of documented non-pharmacological interventions.
Failure to provide pharmaceutical services per facility policy: delayed medication administration for Residents 42, 302, 305, 601, 602; inaccurate controlled substance documentation for Residents 14, 302, 303; and medication errors for Residents 301 and 602.
Failure to store drugs, biologicals, and medical supplies safely: opened medical supplies not properly disposed; discontinued medications not properly discarded.
Failure to maintain sanitary kitchen conditions including dirty ice machine, microwave, kitchen hood, utensils, cutting boards, can opener, blender, and expired foods.
Failure to accommodate drink preferences for Resident 12; milk not served with lunch as ordered.
Failure to implement infection prevention and control program: improper PPE use by staff, improper storage of N95 respirator, improper storage of clean and soiled linens, and lack of Legionella risk assessment and testing.
Report Facts
Medication error rate: 16.13
Medication administration delay: 60
Controlled medication count discrepancy: 1
Medication administration times: 1341
Medication administration times: 1040
Medication administration times: 1108
Medication administration times: 1203
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Failed to notify physician of Resident 598's neurological status change |
| LVN 4 | Licensed Vocational Nurse | Failed to administer medications as ordered for Residents 301 and 602; failed to safeguard PHI; medication administration delays |
| LVN 2 | Licensed Vocational Nurse | Medication administration delays for Residents 601 and 602; failed to administer medications as ordered for Resident 602 |
| CNA 1 | Certified Nursing Assistant | Failed to change gown and gloves and perform hand hygiene between residents |
| CNA 6 | Certified Nursing Assistant | Improper storage of resident shower bin and bathrobe belts |
| DON | Director of Nursing | Acknowledged multiple findings including medication errors, infection control failures, and facility deficiencies |
| Administrator | Acknowledged multiple findings including medication errors, infection control failures, and facility deficiencies | |
| IP | Infection Preventionist | Provided infection control interview and acknowledged failures |
| EVS Director | Environmental Services Director | Responsible for water management program and acknowledged lack of Legionella testing |
| Dietary Supervisor | Acknowledged kitchen sanitation deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 5, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to accommodate a resident's food allergies and preferences, specifically serving dairy milk to a resident allergic to dairy products.
Complaint Details
The complaint investigation found that Resident 1 was served dairy milk despite a documented allergy, confirmed by medical records and interviews. The Dietary Supervisor and DON acknowledged the failure and potential for severe allergic reactions.
Findings
The facility failed to ensure that Resident 1's dairy allergy was respected, resulting in the resident being served milk despite documented allergies. Interviews with the Dietary Supervisor and Director of Nursing confirmed the error and acknowledged the potential for severe allergic reactions.
Deficiencies (1)
Facility failed to ensure Resident 1's food preferences and allergies were followed, serving milk despite a dairy allergy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Interviewed and verified the resident was served milk despite dairy allergy. | |
| Director of Nursing (DON) | Interviewed and acknowledged the resident should not have been served milk or dairy products. |
Inspection Report
Annual Inspection
Census: 107
Capacity: 160
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection of the facility.
Findings
The inspection found no deficiencies. The facility was observed to be clean, well-maintained, and compliant with all regulations including fire safety, resident room furnishings, and staff training documentation.
Report Facts
Resident rooms inspected in assisted living: 7
Staff files reviewed: 10
Care staff files reviewed: 7
Resident files reviewed: 10
Hospice waiver approved residents: 25
Memory care rooms: 12
Resident rooms in facility: 112
Fire drill date: Apr 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during inspection |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection visit |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 107
Capacity: 160
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection of the facility.
Findings
No deficiencies were observed or cited during the visit. The facility was found to be clean, organized, and compliant with all required regulations including safety, staffing, resident care, and documentation.
Report Facts
Resident rooms inspected in assisted living: 7
Staff files reviewed: 10
Care staff files reviewed: 7
Resident files reviewed: 10
Hospice waiver approved residents: 25
Memory care rooms: 12
Fire drill date: Apr 19, 2024
Hot water temperature range: 107.0 to 112.4
Food supply days: 2
Food supply days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 160
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The visit was an unannounced case management follow-up on an incident report submitted on 04/25/2023 regarding allegations of a former employee having sexual relations with female residents.
Complaint Details
The complaint involved allegations that a former employee was having sexual relations with female residents. The employee had resigned on 02/09/2023. Interviews and evidence reviewed did not substantiate the complaint.
Findings
Interviews with the reporting resident, six additional residents, and three staff members were unable to corroborate the incident. No citations were noted during the visit.
Report Facts
Residents interviewed: 7
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the unannounced case management visit and interviews |
| Armando J Lucero | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 91
Capacity: 160
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report submitted on 04/25/2023 regarding allegations involving a former employee.
Complaint Details
The visit was complaint-related following an incident report alleging a former employee was having sexual relations with female residents. The allegation was not substantiated based on interviews and evidence reviewed.
Findings
Interviews with the resident who reported the incident, six additional residents, and three staff members found no corroboration of the alleged incident. No citations were noted during the visit.
Report Facts
Capacity: 160
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and provided information related to the incident report |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the unannounced case management visit and interviews |
Inspection Report
Routine
Deficiencies: 15
Date: Apr 7, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication administration, resident care, infection control, food service, and safety.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document residents' self-administration of medications, inconsistent application of care plans, medication administration errors, improper storage of medications and supplies, failure to follow dietary menus and resident preferences, inadequate infection control practices including hand hygiene and PPE use, and lack of regular inspection of beds and side rails for entrapment risks.
Deficiencies (15)
Failure to assess and document residents' ability to self-administer medications, including lack of physician orders and care plans for Residents 27 and 497.
Failure to provide appropriate treatment and care according to orders, including lack of monitoring of Resident 296's pacemaker and inconsistent use of anti-embolism stockings for Resident 41.
Failure to provide necessary treatment and services to maintain or improve range of motion and orthotic device use for Resident 10.
Failure to provide necessary pharmacy services, including discrepancies between drug control records and medication administration records for Resident 37.
Failure to monitor side effects of psychotropic medication (Trazadone) for Resident 41.
Medication error rate exceeded 5%, including incorrect dosing and administration errors by licensed nurses LVN 4 and LVN 5.
Failure to store drugs and biologicals properly, including unlocked medications at bedside, expired supplies in medication carts, and improper storage temperature for medications.
Failure to follow menus, including serving soup not on menu, incorrect scoop sizes, incorrect bread served for pureed diets, and missing pureed bread for Resident 11.
Failure to ensure food served was palatable and attractive, including serving pureed bread and unappealing meals to Resident 296.
Failure to provide food prepared in a form designed to meet individual needs, including serving minced instead of chopped food for residents on soft-and-bite sized diet.
Failure to accommodate resident allergies, intolerances, and preferences, including failure to provide fruit cups to Residents 344, 345, and 346 when requested and documented.
Failure to maintain sanitary conditions in the kitchen, including unclean ice machine, unlabeled food items, chipped cooking utensils, and heavily marred cutting boards.
Failure to implement infection prevention and control program, including failure of staff to perform hand hygiene before and after assisting residents with meals, and improper use of PPE.
Failure to keep essential equipment working safely, including ice buildup in residents' refrigerators.
Failure to regularly inspect bed frames, mattresses, and bed rails for safety and entrapment risks, including lack of inspection in seven entrapment zones for Resident 30's bed.
Report Facts
Residents sampled: 17
Medication error rate: 15.38
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Named in medication self-administration and medication error findings |
| LVN 5 | Licensed Vocational Nurse | Named in medication error and medication administration findings |
| RN 1 | Registered Nurse | Named in medication self-administration and expired supplies findings |
| RN 2 | Registered Nurse | Named in medication monitoring and orthotic device care findings |
| RN 3 | Registered Nurse | Named in pacemaker care findings |
| LVN 6 | Licensed Vocational Nurse | Named in pharmacy service findings |
| CNA 3 | Certified Nursing Assistant | Named in PPE use and infection control findings |
| CNA 5 | Certified Nursing Assistant | Named in hand hygiene and infection control findings |
| Maintenance Director | Named in equipment maintenance and bed safety inspection findings | |
| DON | Director of Nursing | Named in multiple findings including medication self-administration, orthotic care, and bed safety |
| RD | Registered Dietitian | Named in food service and kitchen sanitation findings |
| DSS | Dietary Services Supervisor | Named in food service and kitchen sanitation findings |
| IP | Infection Preventionist | Named in infection control findings |
| ST | Speech Therapist | Named in dietary texture and food preparation findings |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident access to medical records, specifically addressing a failure to provide requested medical records for a discharged resident.
Findings
The facility failed to provide all requested medical records for one of two sampled residents, potentially delaying necessary services after discharge. Interviews and document reviews confirmed incomplete record provision and lack of documented evidence that all requested records were provided.
Deficiencies (1)
Failure to provide requested medical records for a discharged resident within the required timeframe.
Report Facts
Date survey completed: Mar 20, 2023
Date medical record request form: Dec 16, 2022
Date of partial record sent: Jan 10, 2023
Date of closed medical record initiation: Feb 6, 2023
Resident discharge date: Oct 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records Director | Interviewed regarding tracking of medical records requests | |
| Medical Records Assistant | Involved in email correspondence about partial record provision | |
| Administrator | Interviewed regarding confirmation of medical records provided |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including medication mismanagement, failure to give 30 day notice, inadequate hydration, unsafe bathroom conditions, and lack of supplies.
Complaint Details
The complaint investigation was initiated based on allegations received on 2022-10-06. The substantiated allegation involved inaccurate resident records being shared. Other allegations were found unsubstantiated or unfounded.
Findings
The investigation found one substantiated deficiency related to inaccurate resident records being shared with families, posing a risk to resident confidentiality. All other allegations including medication mismanagement, failure to give notice, hydration, bathroom safety, and supplies were found to be unfounded or unsubstantiated.
Deficiencies (1)
Facility staff did not keep accurate records on resident(s), including erroneously submitting unrelated resident documents to a family, risking confidentiality.
Report Facts
Facility capacity: 160
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator | Met with during investigation and named in report |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
Unannounced complaint investigation visit conducted to investigate multiple allegations including medication mismanagement, failure to give 30 day notice, inadequate hydration, unsafe bathroom environment, and lack of supplies.
Complaint Details
The complaint investigation was triggered by multiple allegations received on 10/06/2022 regarding medication mismanagement, failure to give 30 day notice, inadequate hydration, unsafe bathroom environment, lack of supplies, and inaccurate record keeping. The allegation of inaccurate record keeping was substantiated, while others were found to be unsubstantiated or unfounded.
Findings
The investigation found one substantiated deficiency related to inaccurate resident records being shared, posing a risk to confidentiality. All other allegations including medication mismanagement, failure to give notice, hydration, bathroom safety, and supplies were found to be unfounded or unsubstantiated.
Deficiencies (1)
Licensee failed to maintain confidentiality of resident records by erroneously including unrelated documents pertaining to other residents.
Report Facts
Facility capacity: 160
Visit time: 2
Plan of Correction due date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Johanna Gonzalez | Administrator | Facility administrator met during the investigation and named in the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Capacity: 160
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
The visit was an unannounced case management follow-up to deliver findings on an investigation completed by the Department regarding a resident's death.
Complaint Details
The visit was related to a complaint investigation concerning the death of Resident 1. The allegation was determined to be unsubstantiated as there was no preponderance of evidence proving the alleged violation occurred.
Findings
The investigation revealed that Resident 1, who was independent except for medication management, was found deceased due to asphyxiation with a plastic bag over the head. The investigation found no evidence of lack of care or supervision contributing to the death, and the allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Adam Alvarado | Maintenance Director | Greeted Licensing Program Analyst and granted entry to the facility |
| Johanna Gonzalez | Administrator | Facility Administrator named in the report header |
Inspection Report
Follow-Up
Census: 160
Capacity: 160
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
An unannounced case management visit was conducted to deliver findings on an investigation completed by the Department regarding a resident's death and to follow up on the investigation.
Complaint Details
The visit was complaint-related, investigating the circumstances surrounding Resident 1's death. The allegation was determined to be unsubstantiated due to lack of evidence proving a violation occurred.
Findings
The investigation revealed that Resident 1, who was independent except for medication management, was found deceased due to asphyxiation with a plastic bag over the head. The investigation found no evidence of lack of care or supervision causing the death, and the allegation was determined to be unsubstantiated.
Report Facts
Capacity: 160
Census: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Adam Alvarado | Maintenance Director | Greeted the Licensing Program Analyst and granted entry into the facility |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation and visit |
Inspection Report
Census: 102
Capacity: 160
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident report received regarding a resident who was taken to the ER and sustained a pelvic fracture.
Findings
The Licensing Program Analyst reviewed resident records and incident details but found no deficiencies at this time. Further follow-up is planned to gather more information on the incident.
Report Facts
Incident report date: Jan 27, 2023
Incident date: Jan 22, 2023
Medication administration date: Jan 22, 2023
Belongings pickup date: Jan 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during visit and discussed incident |
| Lydia Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and reviewed incident |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 160
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
The visit was an unannounced Case Management follow-up on an incident report received regarding Resident 1 being taken to the ER for leg pain and sustaining a pelvic fracture.
Complaint Details
The visit was triggered by an incident report dated 01/27/2023 concerning Resident 1's whereabouts and injury. The complaint is under follow-up with no substantiation status stated yet.
Findings
The Licensing Program Analyst reviewed Resident 1's records and incident details but found no deficiencies at this time. Further follow-up is planned to gather more information on the incident.
Report Facts
Facility capacity: 160
Resident census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Discussed purpose of visit and unable to state when Resident 1 was picked up |
| Lydia Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and follow-up |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 160
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report submitted regarding a missing $600 from a resident's purse.
Complaint Details
Incident involved a missing $600 reported by Resident 1's sister on 09/29/2022. Newport Beach police were notified and a case was created. The officer stated the matter is being documented only at this time.
Findings
No citations were noted during the visit. The facility reported no other similar complaints and no suspicion of a perpetrator. The resident was interviewed privately to gather their account.
Report Facts
Missing cash amount: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced case management visit and interview. |
| Alisa Ortiz | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 160
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident report submitted regarding a missing $600 from a resident's purse reported on 09/29/2022.
Complaint Details
The complaint involved a missing $600 reported by Resident 1's sister. The Newport Beach police were notified and a case was created, but the officer stated it was being documented only at this time. No other similar complaints were recorded.
Findings
No citations were noted during the visit. The facility had no suspicion of a perpetrator, and the resident's family was advised to avoid leaving large sums of cash in the resident's bedroom.
Report Facts
Missing cash amount: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 160
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report received regarding a resident alleging inappropriate touching by another resident.
Complaint Details
Incident report dated 08/25/2022 indicated Resident 1 advised home health nurse of inappropriate touching by a male resident. Police responded and took a report. Facility investigation was inconclusive. Resident was escorted for two weeks. Resident verbalized no concern during visit.
Findings
The facility conducted an investigation but was unable to identify the alleged male resident due to lack of information. The resident was placed on escorting for two weeks and reported feeling safe during the visit. No deficiencies were noted during the visit.
Report Facts
Escort duration (weeks): 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Alisa Ortiz | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 89
Capacity: 160
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report received by Community Care Licensing regarding an allegation of inappropriate touching of a resident.
Complaint Details
Incident report dated 08/25/2022 indicated Resident 1 advised home health nurse of inappropriate touching by a male resident. Police responded and took a report. Facility investigation was inconclusive. Resident was placed on escorting for two weeks. Resident verbalized no concern during visit and felt safe.
Findings
The facility conducted an investigation but was unable to identify the alleged male resident involved. The resident was placed on escorting for two weeks and reported feeling safe during the visit. No deficiencies were noted during the visit.
Report Facts
Escort duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Johanna Gonzalez | Executive Director | Discussed the purpose of the visit and was met during the inspection. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 160
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction at Atria Newport Plaza.
Complaint Details
The complaint alleged unlawful eviction. The investigation was unannounced and included interviews, facility tour, and document review. The allegation was found to be unfounded.
Findings
The investigation found that Resident 1 was hospitalized and had a prohibited medical condition (tunneled port catheter for dialysis). The facility required a 24-hour nurse for the resident's return, which the family declined, leading to the resident's removal by family. The allegation of unlawful eviction was deemed unfounded.
Report Facts
Capacity: 160
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Johanna Gonzalez | Executive Director | Facility representative met during investigation |
Inspection Report
Census: 89
Capacity: 160
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
An unannounced health and safety case management visit was conducted to assess the facility's compliance and resident well-being following a recent resident death.
Findings
No health or safety violations were noted during the visit. The facility was observed with residents participating in activities and relaxing in common areas. The resident who died had no prior observed suicidal ideations or behaviors since admission.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced health and safety case management visit. |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 89
Capacity: 160
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
An unannounced health and safety case management visit was conducted to assess the facility's compliance and resident well-being.
Findings
No health or safety violations were noted during the visit. The facility was observed with residents participating in activities and relaxing in common areas. A resident was found deceased by self-inflicted injury earlier that morning, but no violations were identified related to this incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced health and safety case management visit. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 160
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction at the facility.
Complaint Details
The complaint alleged unlawful eviction. The investigation determined the allegation to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the allegation of unlawful eviction was unfounded. Resident 1 was hospitalized and had a prohibited medical condition; the family declined the facility's condition for return, and the resident was moved out by the family.
Report Facts
Capacity: 160
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Johanna Gonzalez | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 160
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
Unannounced case management visit to follow up on incident reports received by Community Care Licensing regarding residents found outside the facility and suicidal ideations.
Complaint Details
The visit was triggered by incident reports: Resident 1 was found outside the facility gate near a gas station and Resident 2 was sent to the hospital after verbalizing suicidal ideations. Resident 1 has a diagnosis of Dementia and is unable to leave unassisted. Resident 2 has Mild Cognitive Impairment with no mental health diagnosis. Both residents were found safe and satisfied with the facility.
Findings
The visit found that Resident 1 was found outside the facility but redirected with no adverse effects, and Resident 2 was sent to the hospital for suicidal ideations but returned cleared. Both residents expressed satisfaction and appeared well cared for. No deficiencies were noted during the visit.
Report Facts
Incident report date: Jul 18, 2022
Incident report date: Jul 7, 2022
Physician report date: Jul 13, 2022
Physician report date: Apr 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during visit and discussed purpose of visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
Inspection Report
Census: 94
Capacity: 160
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports received by Community Care Licensing involving two residents.
Findings
The visit found that Resident 1 was found outside the facility but was safely redirected back, and Resident 2 was sent to the hospital for suicidal ideations but returned with no medication changes. Both residents expressed satisfaction and felt safe. No deficiencies were noted during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 160
Deficiencies: 0
Date: May 18, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports received by Community Care Licensing involving a fire incident and a resident altercation in the memory care unit.
Complaint Details
The visit was triggered by incident reports dated 05/13/2022 and 05/16/2022 involving a microwave fire in a resident's room and an altercation between two residents in the memory care unit. No injuries or open wounds were noted, and residents were assessed as safe.
Findings
The visit found no deficiencies; the fire incident was managed without injury and the residents involved in the altercation appeared safe and well cared for during the visit.
Report Facts
Incident report dates: 05/13/2022 and 05/16/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
Inspection Report
Census: 90
Capacity: 160
Deficiencies: 0
Date: May 18, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports received by Community Care Licensing.
Findings
Two incidents were reviewed: a microwave fire in a resident's room which was extinguished with no injuries, and an altercation between two residents in the memory care unit with no injuries. Both residents appeared safe and well cared for during the visit. No deficiencies were noted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 86
Capacity: 160
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required annual inspection of the facility.
Findings
No deficiencies were noted during the visit. The facility appeared clean, sanitary, and well maintained with residents appearing happy and well cared for. All resident files were up to date and the facility had approved mitigation plans and emergency supplies.
Report Facts
Residents on hospice care: 5
Residents in Assisted Living: 71
Residents in Memory Care: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator | Facility Administrator present during the inspection |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 160
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident report received on 2021-02-07 regarding an agency caregiver allegedly speaking inappropriately to a resident.
Complaint Details
The complaint involved Resident 1 reporting inappropriate speech by an agency caregiver. The facility notified the agency and barred the staff member from returning. The resident refused to speak with police and did not disclose details during the visit. The complaint was not substantiated further.
Findings
The Licensing Program Analyst spoke with the resident involved, who refused to disclose the inappropriate comment but expressed feeling safe and satisfied with facility caregivers. No further investigation was required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Discussed the purpose of the visit with the Licensing Program Analyst. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
Inspection Report
Annual Inspection
Census: 86
Capacity: 160
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility appeared clean, sanitary, and well maintained with all required elements in resident rooms and restrooms. No deficiencies were noted during the visit, and residents appeared happy and well cared for.
Report Facts
Residents on hospice care: 5
Residents in Assisted Living: 71
Residents in Memory Care: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Administrator | Facility administrator present during the inspection |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection visit |
| Alisa Ortiz | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 86
Capacity: 160
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report (SOC 341) received on 2021-02-07 regarding an agency caregiver's inappropriate communication with a resident.
Complaint Details
The visit was complaint-related following an incident report alleging inappropriate communication by an agency caregiver. The resident refused to speak with police and did not disclose details during the visit.
Findings
The resident refused to disclose the inappropriate comment but expressed feeling safe and satisfied with facility caregivers. No further investigation was required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 160
Deficiencies: 0
Date: Nov 22, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility was wrongfully evicting a resident.
Complaint Details
The complaint alleged wrongful eviction of a resident. The allegation was investigated and found to be unfounded as the facility did not issue an eviction notice and only advised the responsible party of the need for memory care placement due to the resident's decline.
Findings
The investigation found that the resident eloped from the facility and needed to be moved to a memory care unit, which currently had no openings. The facility provided a one-on-one caregiver and offered other facility options, which were declined by the family. The allegation of wrongful eviction was determined to be unfounded.
Report Facts
Capacity: 160
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Johanna Gonzalez | Executive Director | Met with the evaluator and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 160
Deficiencies: 0
Date: Nov 22, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility was wrongfully evicting a resident.
Complaint Details
The complaint alleged wrongful eviction of a resident. The allegation was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Findings
The investigation found that the resident eloped from the facility and required memory care placement, which was not immediately available. The facility provided a one-on-one caregiver and offered other facility options, which the family declined. No eviction notice was given, and the allegation was deemed unfounded.
Report Facts
Capacity: 160
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Johanna Gonzalez | Administrator / Executive Director | Met with the investigator and provided information during the investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 98
Capacity: 160
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
Licensing Program Analyst Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report dated 11/07/2021.
Findings
Four residents exited the facility without authorization but were redirected back inside. All four residents are unable to leave the facility per physician report. Two residents are being referred to the memory care unit. During the visit, three residents were observed participating in activities and two residents verbalized feeling safe and cared for.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Discussed the purpose of the visit with Licensing Program Analyst Kimberly Lyman. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Census: 98
Capacity: 160
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report dated 11/07/2021 involving four residents who exited the facility grounds.
Findings
The visit found that all four residents were unable to leave the facility per physician report, two residents were referred to the memory care unit, and three residents were observed participating in activities and reported feeling safe and cared for.
Report Facts
Residents involved in incident: 4
Residents observed: 3
Residents verbalized: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 98
Capacity: 160
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The visit was an unannounced case management follow-up on incident reports submitted on 10/18/2021 and 10/26/2021 related to resident safety incidents at the facility.
Findings
The inspection found that one resident was found on the roof attempting to end their life and was hospitalized, and another incident involved two residents in an altercation with no injuries. The facility took appropriate actions including calling emergency services and police, and no further action was required.
Report Facts
Incident report dates: Incident reports dated 10/17/2021 and 10/25/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
Inspection Report
Census: 98
Capacity: 160
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports submitted to Community Care Licensing on 10/18/2021 and 10/26/2021.
Findings
The visit reviewed two incidents: one involving a resident found on the roof attempting self-harm and another involving an altercation between two residents with no injuries. The facility was observed and discussed with staff, and no further action was required at this time.
Report Facts
Incident report dates: Incident reports dated 10/17/2021 and 10/25/2021 were reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Discussed purpose of visit and involved in incident follow-up. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 160
Deficiencies: 1
Date: Jun 18, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not seek timely medical attention for a resident.
Complaint Details
The complaint was substantiated. The allegation that the facility did not seek timely medical attention for a resident was found to be true based on investigation findings.
Findings
The investigation substantiated that the facility failed to provide timely medical attention to a resident who was found on the floor with a skin tear and bleeding but was not sent out for evaluation. The resident later passed away due to cardiac arrest. The facility was cited for failure to ensure adequate care and supervision.
Deficiencies (1)
Basic services shall at a minimum include care and supervision as defined in regulations. Licensee failed to ensure care and supervision was provided to resident in care who was found on the floor with a skin tear, bleeding, and dizziness and was not sent out for evaluation.
Report Facts
Capacity: 160
Census: 101
Plan of Correction Due Date: Jun 25, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Myra Aragones | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 160
Deficiencies: 1
Date: Jun 18, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not seek timely medical attention for a resident.
Complaint Details
The complaint was substantiated based on the preponderance of evidence. The allegation was that the facility did not seek timely medical attention for a resident who fell and was injured.
Findings
The investigation substantiated the allegation that the facility failed to provide timely medical attention to a resident who was found on the floor with a skin tear and bleeding. The resident was not sent out for evaluation despite facility policy to call 911 for falls with possible head injury or larger lacerations. The resident subsequently passed away.
Deficiencies (1)
Licensee failed to ensure care and supervision was provided to resident in care. Resident was discovered on the floor with a skin tear, bleeding, and dizziness and was not sent out for evaluation, posing a potential health and safety risk.
Report Facts
Census: 101
Total Capacity: 160
Plan of Correction Due Date: Jun 25, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Myra Aragones | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 160
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff handled a resident in a rough manner and did not return the resident's personal belongings.
Complaint Details
The complaint was investigated and deemed unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Findings
The investigation found that the allegations were unfounded. Observations and interviews indicated that the resident's belongings were present and staff denied rough handling, noting the resident had behaviors requiring extra care.
Report Facts
Complaint Control Number: 22-AS-20201228162326
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Johanna Gonzalez | Executive Director | Discussed the purpose of the visit with the Licensing Program Analyst. |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 101
Capacity: 160
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports submitted to Community Care Licensing.
Findings
The visit reviewed incidents involving Resident 1 who became aggressive and required a psych evaluation and one-on-one companion, and Resident 2 who was found deceased. No citations were noted during the visit.
Report Facts
Incident report date: May 16, 2021
Death report date: May 10, 2021
Resident 1 move out date: Jun 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report |
Inspection Report
Census: 101
Capacity: 160
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports submitted to Community Care Licensing.
Findings
The visit reviewed incidents involving Resident 1 who became aggressive and required a psych evaluation, and Resident 2 who was found deceased. No citations were noted during the visit.
Report Facts
Capacity: 160
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Gonzalez | Executive Director | Met with Licensing Program Analyst during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Dec 20, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, confidentiality, pharmaceutical services, drug storage, food safety, and infection control.
Findings
The facility was found deficient in maintaining resident dignity during wound treatment, protecting resident identifiable information, ensuring availability of PRN pain medication, proper labeling and storage of drugs and food, and maintaining sanitary conditions for equipment storage. These deficiencies posed potential risks for harm, including loss of dignity, medication errors, foodborne illness, and cross contamination.
Deficiencies (6)
Failed to ensure the door to the room of one resident remained closed during wound treatment, risking loss of dignity.
Failed to protect resident identifiable information by including confidential resident rosters in a publicly accessible survey results binder.
Failed to obtain and ensure availability of PRN pain medication for one resident, risking medication errors and lack of needed medication.
Failed to ensure an opened vial of flu vaccine was discarded timely, risking administration of expired vaccine.
Failed to ensure proper labeling and dating of food items in residents' refrigerator, risking foodborne illness.
Failed to ensure clean equipment was stored properly, with oxygen concentrators and PPE found inside a public restroom, risking cross contamination.
Report Facts
Deficiencies cited: 6
Medication order date: Nov 27, 2019
Last dose date: Dec 11, 2019
Inspection date: Dec 17, 2019
Inspection date: Dec 19, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Observed leaving Resident 245's door open during wound treatment |
| MDS Coordinator | Interviewed regarding process to refill PRN Dilaudid medication | |
| DON | Director of Nursing | Interviewed regarding medication refill procedures and documentation |
| LVN 4 | Licensed Vocational Nurse | Inspected medication cart and interviewed about medication refill documentation |
| LVN 1 | Licensed Vocational Nurse | Inspected medication storage and interviewed about flu vaccine discard |
| Maintenance Director | Interviewed about storage of clean equipment in public restroom | |
| DSS | Interviewed about labeling of residents' food items in refrigerator |
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