Clearwater Newport Beach

Type of visit: Case Management - Incident

On July 8, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Taylor Simerly made an unannounced visit to the facility to conduct a Case Management - Incident inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Dee Navarro was present and assisted on today's visit. LPAs are conducting the visit to follow up on a self reported Unusual Incident/Injury Report (UIIR) that was submitted to the Orange County Regional Office on July 2, 2026. The UIIR described that Resident #1 (R1) was given the incorrect dosage of her prescribed Tolvaptan 15 MG tablet routine medication on June 28, June 29, and June 30, 2026. During today's visit, LPAs reviewed and collected pertinent documents such as R1's identification sheet, medical assessment, active medication orders, and medication administration records. LPAs conducted an interview with R1, however, R1 was unable to provide any information regarding the incident. LPAs also conducted two staff interviews. Both staff interviewed confirmed that the UIIR submitted to the Orange County Regional Office was correct and that a medication error did occur with R1 on three separate occasions in June 2026. LPAs also reviewed the medication administration records for R1 for July 2026 and observed that R1 was also given the incorrect dosage of her prescribed Tolvaptan 15 MG tablet routine medication on July 1, 2026. Based on the information gathered during the visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Executive Director Dee Navarro. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 9, 2026

87465 Incidental Medical and Dental Care(a): A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not evidenced by: Based on interviews conducted & records reviewed, the Licensee did not ensure that R1 was given her routine medication according to the prescribed orders on four different occasions. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: The Executive Director stated that a retraining with all staff handling medication has been scheduled. The Executive Director agreed to provide LPAs proof of the training for all staff via email or fax by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated May 26, 2026. LPA was greeted and granted entry by Executive Director (ED) Kathleen Olson. LPA explained the reason for the visit. Per UIIR, on May 24, 2026, resident 1 (R1) was getting up, lost his balance and fell backwards. Per UIIR, R1 was admitted to the Hospital for multiple back fractures. Per UIIR, the Neurosurgeon recommended surgery for R1. During today's visit LPA reviewed the Death Report dated June 4, 2026, for R1. Per Death Report, on May 30, 2026, R1 passed away at the Hospital. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Olson and a copy of this report were provided at the time of exit.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez Jr. made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by Executive Director (ED) Kathleen Olson. LPA explained the reason for the visit. During the inspection, LPA and ED conducted a tour of the inside and outside of the facility, common areas, resident bedrooms, and observed the following: The facility consists of a three story building, with memory care being on the second floor. The building has common areas which include, a dining room, multiple activity rooms, multiple outside areas with shaded seating, and a Wellness center. LPA observed the See Something, Say Something (PUB 475) poster mounted on the residents' mail room wall by the entryway of the facility. LPA inspected resident bedrooms in both assisted living and memory care. LPA observed resident bedrooms to be clear of any hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. Signal system was tested and observed to be operational with a two minute response time. The delayed egress in the memory care was tested; LPA observed that the delayed egress was operational. Bathrooms were observed to have functioning faucets and toilets, textured shower floors, and grab bars. Water temperature tested between 114.8-116.2 degrees Fahrenheit. LPA observed that the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. LPA observed the emergency food and water supply. CONTINUED ON LIC809-C... LPA reviewed the Fire Sprinkler System reports dated February 2, 2026. LPA observed that the inspection was passed and the Sprinkler System was observed to be operational. The last fire drill was conducted on January 28, 2026. LPA observed fire extinguishers mounted throughout the facility. The fire extinguishers were last service on October 24, 2025. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in a medication cart located within the medication rooms. The medication rooms are located on the second and third floor. LPA reviewed the centrally stored medication for residents and did not observe any discrepancies. LPA reviewed five resident files and four staff files, no discrepancies were observed. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 20, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated January 14, 2026. LPA was greeted and granted entry by Executive Director (ED) Kathleen Olson. LPA explained the reason for the visit. Per UIIR, as of December 12, 2025, Resident 1 (R1) had an order to take Valganciclovir HCI 450 mg 1 tablet twice a day for 14 days. Per UIIR, on December 27, 2025, order was decreased to Valganciclovir 450 mg 1 tablet once daily and discontinued on EMAR. Per UIIR, R1 did not receive the medication for 17 days. During today's visit LPA reviewed the Physician's orders dated December 10, 2025, for R1. Per Physician's orders under instructions it states restart valcyte 450 mg 1 tab x 14 days then decrease to 1 tab daily starting December 27, 2025. Per Physician's orders dated January 13, 2026, R1 was prescribed Valganciclovir 450 mg 1 tab po bid x 14 days then decrease to 1 tab po daily starting January 28, 2026. Per UIIR, the medication was restarted on January 13, 2026. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Olson and a copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Feb 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(c)(2) · Plan of correction due date: Feb 23, 2026

Incidental Medical and Dental Care. (a) If the resident's physician has stated in writing ... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Per UIIR, R1 was not given their prescribed Valganciclovir 450 mg for 17 days. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee to provide an in-service Medication training to staff and email POC to LPA by POC due date.

Allegation investigated: Facility staff did not assess resident's medical condition and need appropriately.

On November 21, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Kathleen Olson The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of a resident’s service records which include Physician’s Report, Appraisal Needs and Services Plans, Identification and Emergency information, admission agreement, facility progress notes, and other document records. LPA conducted interviews with seven staff. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility staff did not assess resident's medical condition and need appropriately. It is alleged an altercation between resident and staff occurred. It is alleged the resident was not aggressive during this time and was sent to the hospital. No communication was provided to the resident’s responsible party prior to the incident and why the resident was sent to the hospital. Based on record review, resident #1 (R1) has a history of being physically and verbally aggressive with staff. Admission Agreement was signed and dated October 15, 2024, which was the same day R1 was admitted to the facility. Physician’s report dated October 8, 2024, R1 was diagnosed with dementia and has concerns with confusion and sun downing behavior. Facility progress notes for the incident dated January 5, 2025, stated medication technician responded to a request from staff in regard to R1. Medication technician arrived to assist the staff because R1 entered another resident’s room. Staff tried to redirect R1 away from the room, but R1 would kick, punch, and twist the staff’s hand. It is noted that R1 was transported to a hospital due to being aggressive with staff. Prior to R1 leaving the facility, another facility progress note entry from January 5, 2025, stated S3 reached out to the resident’s responsible party to inform them that R1 needed to be sent out to the hospital because of their behaviors. It is noted the responsible party agreed to S3’s assessment. The facility progress notes also stated that R1 was physically and verbally aggressive with staff while R1 was being escorted to the emergency services unit. Emergency Service (EMS) record dated January 5, 2025, revealed that EMS arrived at 1:59 PM due to R1’s violent behavior and left the scene at 2:24 PM. The resident was admitted to the hospital on January 5, 2025, at 2:45PM, for restlessness, agitation, and personal history of other mental and behavioral disorders. Hospital records on page 2 stated R1 was admitted to the Hospital’s Brain Spine unit on January 13, 2025. Preplacement Appraisal Needs and Service plan dated October 1, 2024, stated R1 had severe confusion or forgetfulness, and moderate aggressive behavior. R1’s service plan with the last assessment dated on November 19, 2024, stated R1 has current or history of occasional disruptive, aggressive, or socially inappropriate behavior. It also notes R1 may require special tolerance or staff training. R1’s Service Plan with an assessment date of December 27, 2024, stated R1 is verbally or physically inappropriate, and requires supervision such as a professionally authorized behavioral management program. Facility progress notes dated December 5, 2024, R1 was aggressive with staff by kicking and punching care staff as they attempted to help R1 shower. Continued on LIC9099C Facility Progress notes dated December 8, 2025, R1 was aggressive to care staff by grabbing them and then turned a table over and a TV over. Facility progress noted dated January 4, 2025, R1 came out of a care room in need to use the bathroom. Staff noted the care room had remnants of bowel movement on the carpet and trash can. Staff attempted to wash up R1 for hygiene and dignity, which led to R1 being upset because R1 wanted to leave the bathroom. While staff attempted to clean up R1, R1 kicked, punched, scratched, yelled, and attempted to bite the staff. The facility assessed R1’s medical conditions as conditions changed and applied the service plans to meet R1’s needs. Based on interviews conducted seven out seven staff denied the allegation. One out of one witness confirmed the allegation. All staff stated they were aware of R1’s medical conditions. All staff logged in their incidents and presented it to the Memory Support Director and/or any other supervisor what was going on. All staff stated they followed protocol in redirecting, assisting, or caring for R1, when R1 exhibited aggressive behavior. They all stated they were given updates with R1 with procedures, protocol, and how to proceed. Based on interviews conducted with S4, S6, and S7, they attempted to redirect R1 out of another resident’s room on January 5, 2025, but this led R1 to be aggressive with them by kicking, punching, and twisting their arms. They all confirmed that R1 was sent to the hospital on January 5, 2025. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all staff denied that the facility staff did not assess resident’s medication and need appropriately. The facility kept a record of whenever R1’s condition changed. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegation facility staff did not assess resident's medical condition and need appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report and LIC811 were provided to Executive Director Kathleen Olson.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 22-AS-20250207150705

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated August 27, 2025. LPA was greeted and granted entry by Executive Director (ED) Krista Solomon. LPA explained the reason for the visit. Per UIIR during the morning of August 25, 2025, Resident 1 (R1) was given two doses of amlodipine, levothyroxine, and vitamin D3. During today's visit LPA reviewed the Physician's orders dated September 10, 2025, for R1. Per Physician's orders R1 is prescribed Amlodipine Besylate 5 mg, one tablet by mouth twice daily. Per Physician's orders R1 is prescribed levothyroxine Sodium 100 mcg, one tablet by mouth daily. Per Physician's orders R1 is prescribed vitamin D3, 25 mcg, one tablet by mouth daily. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Solomon and a copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 11, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: On the morning of 8/25/25 R1 was given two doses of Amlodipine, levothyroxine and vitamin D3. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: On 8/27/25 Licensee conducted an in-service Medication trainings. Licensee to read regulation and sign a statement of understanding. Licensee to email LPA POC by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated April 23, 2025. LPA was greeted and granted entry by Business Office Manager (BOM) Luz Santana. LPA explained the reason for the visit. Per UIIR on April 21, 2025, Resident 1 (R1) was given two tablets of Carbidopa Levodopa 25-100 mg in error. Per UIIR the medication was not prescribed to R1. During today's visit LPA reviewed the Physician's orders dated May 09, 2025, for R1. Per Physician's orders R1 is not prescribed Carbidopa Levodopa 25-100 mg. A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit. Based on observations and records reviewed during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: May 12, 2025

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement was not met as evidence by: R1 was given a medication that was not prescribed to them. Per Physician's orders R1 is not prescribed Carbidopa Levodopa 25-100 mg. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Licensee to provide an in-service Medication training to staff and email POC to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Alvaro Ramirez Jr. and Hanna Gough made an unannounced visit for the purpose of conducting the required annual inspection. Upon entry LPAs were greeted by the receptionist and explained the purpose of the visit. LPAs met with Vice President of Operations (VPO) Maria Rossi. During the inspection, LPAs and VPO conducted a tour of the inside and outside of the facility, common areas, resident rooms, and observed the following: The facility consists of a three story building, with memory care being on the second floor. The building has common areas which include, a dining room, multiple activity rooms, multiple outside areas with shaded seating, and a wellness center. Resident rooms were inspected and all were observed to have the required components and furnishings. LPAs observed all resident beds had clean linens and blankets. Signal system was tested and observed to be operational with a seven minute response time. The delayed egress in the memory care unit was tested by LPAs and found to be operational. Bathrooms were observed to have functioning faucets and toilets with slip mats, textured shower floors, and grab bars. Water temperature tested between 109.2-119.4 degrees Fahrenheit. LPAs observed that the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations with a clean and operational kitchen. LPAs observed the emergency food and water supply. LPAs reviewed the reports for the fire and sprinkler system dated February 4, 2025 and were found to be operational. LPAs reviewed the carbon monoxide reports dated January 8, 2025 and were found to be operational. The last fire drill was conducted on February 10, 2025. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in a medication cart located within the medication rooms. The medication rooms are located on the second and third floor. LPAs reviewed centrally stored medication for residents and did not observe any discrepancies. (Cont. LIC809-C) LPAs reviewed five resident files and four staff files, no discrepancies were observed. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit for the purpose of conducting a health and safety inspection. LPA was greeted and granted entry by Executive Director (ED) Zehra Syed. LPA explained the reason for the visit. LPA conducted a case management visit to follow up on a death report dated January 27, 2025, for Resident 1 (R1). LPA and ED conducted a toured of the facility and observed the facility has electricity, water, and gas. Water temperature tested at 114.4 degrees Fahrenheit. Resident bedrooms were observed to have the required furnishings. Certificate of liability insurance was observed to be current. The kitchen was observed to be clean and organized and a 2-day supply of perishable and a 7-day supply of non-perishable food was observed. Medications are kept locked in a cabinet in the Medication Room. Knives are kept locked in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins, and disinfects were observed to be inaccessible to Residents. During today's visit LPA observed as Residents were having breakfast and/or participating in their morning activities. Based on observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Feb 5, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility and was greeted and granted entry by Receptionist Ami Tynes. LPA then met with Diane Navarro Vice President of Operations. LPA stated the purpose of the inspection. LPA stated they are conducting a Case Management inspection to follow up on medication errors self-reported by the facility. The incident reports were received by Community Care Licensing (CCL) on 2/21/24 and 2/22/24. These reports indicate the following: 1. Med Tech (MT1) did not give scheduled medication to Resident (R1) as ordered on 2/16/24 2. MT1 did not give scheduled medication to R1 as ordered on 2/17/24 3. MT1 applied the wrong cream to R1's abdominal fold on 2/20/24 LPA interviewed the VP of Operations and determined the medication errors were made by the same staff member. VP stated the facility decided to terminate the Med Tech due to multiple medication errors made in less than a week. VP stated R1's family visits R1 daily. VP stated the facility has been in communication with R1's family throughout the medication error and MT1's termination. LPA requested copies of the following documents: 1. R1's Admission Agreement 2. R1's February 2024 physician's orders 3. R1's February 2024 MAR 4. R1's alert charting 5. February 2024 CP/MT Schedule 6. Email: Incident Summary Report 7. Termination Form for MT1 8. Internal Email RE: MT1's Termination. Based on record review, LPA determined the facility terminated MT1 on 2/21/24. LPA determined that the facility took timely and appropriate action to correct the errors made. No deficiencies were noted from today's inspection. An exit interview was conducted with the VP of Operations and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Diana Navarro, Vice President of Operations and brought to the office of the Administrator Robert Johnston. An application to operate a Residential Care Facility for the ElderLY (RCFE) for (120) capacity, (0) ambulatory, (112) non-ambulatory, and (8) bedridden residents was received by CCL on 8/7/2023. Structure - The four-story facility houses Assisted Living (AL) and Memory Care (MC) apartments. The lower level houses the parking garage, 2 common bathrooms, Activities Room, Theater, Salon, Exercise Room, commercial laundry room and Employee offices. The 1st floor houses 21 AL apartments, 2 common bathrooms, Living Room, Club Room, Private Dining Room, Outdoor Patio, Courtyard, Cafe, Kitchen, Common Dining Room, laundry room, loading dock, Reception and employee offices. The 2nd floor houses 9 AL apartments, 31 MC apartments, 1 MC common bathroom, MC Dining Room, MC Living Room, MC Activity Space, MC Salon, 2 MC Patios, AL laundry Room, MC Laundry Room, Chart Room, Med Room, Satellite Kitchen and employee offices. The 3rd floor houses 40 AL apartments, Health Services Office, laundry Room, Chart Room and Med Room. LPA observed the facility to be clean and sanitary. Resident Apartments/Bedrooms/Hot Water - LPA toured 3 model apartments. All apartments have private bathrooms. LPA measured hot water in rooms on each floor. Hot water measured was observed to be between 105 and 120 degrees Fahrenheit. LPA observed all windows were screened. Medications, Files, First-Aid Kit will all be stored in Chart Rooms and Med Rooms. Activities - The facility has an exercise room, a theater, salons, as well as activity rooms equipped with board games, art supplies and more for resident use. Kitchen/Food Service/Emergency Food & Water/Toxins - There is a 2-day supply perishable food and a 7-day supply of non-perishable food on hand. Emergency food supply is located in the kitchen. Emergency water is located in 55-gallon drums. There are 3 on each floor, LPA observed a walk-in refrigerator, a walk-in freezer, a walk-in pantry and noted the kitchen has working appliances and can be locked from all entrances. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the kitchen and laundry rooms. LPA noted the toxins stored in the kitchen are stored separate from food and food-handling items. The Fire Clearance, including the smoke/carbon monoxide detectors/sprinkler system was approved by a fire inspector of Newport Beach Fire Department on 12/21/2023. All fire extinguishers are fully charged. The service tags indicates they were last serviced on 7/28/2023. Emergency Phone Numbers, Exit Plan, Activity Calendar & Menu are all posted and available for review. Component III was reviewed and provided via PDF. Comp III provides a general overview of how to maintain compliance in accordance with regulations. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report and Component III presentation were provided to designated AD.the state’s words, verbatim · CDSS document, Feb 12, 2024