Atria Newport Plaza

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management visit to follow up on an incident report submitted on 04/25/2023 to the Department. LPA met with Executive Director (ED) Johanna Gonzalez and explained the purpose of the visit. Incident report dated 04/25/2023 indicate that on 04/25/2023 at approximately 11:00 a.m., Resident 1 (R1) reported that a former employee was having sexual relations with other female residents. ED stated that employee had resigned on 02/09/2023 to join the Coast Guard and that no other resident had report any such incident. LPA interviewed R1 privately in their bedroom to gather their account of the incident. R1 stated that the former employee had not had sexual relations with them or any other resident that they are aware of. R1 stated former employee had “great customer service” and stated they would be “comfortable” employing them in their own home. LPA interview six additional residents. Six out of six residents were unable to corroborate the incident and stated they have not witnessed nor heard of any such incident taking place. LPA also interviewed three staff. Three out of three staff were also unable to corroborate the incident and stated they have not witnessed nor heard of any such incident taking place. R1 met with Primary Care Physician (PCP) on today’s date at approximately 10:00 a.m. LPA was provided with a current copy of Physician Report (LIC602) dated today’s date and R1’s Psych Evaluation dated 4/16/2023. No citations noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 28, 2023

Allegation investigated: /Facility staff mismanaged resident's medications (resident was overmedicated). 3/ Facility did not give resident a 30 day notice. 4/ Facility staff did not ensure that resident was adequately hydrated. 8/ Facility bathrooms do not provide a safe environment for residents in care (no support commode frames, grab bars). 9/ Facility bathrooms did not have supplies (soap, paper towels, toilet paper).

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Johanna Gonzalez after explaining the purpose of the visit. LPA conducted an initial facility visit on October 11, 2022. LPA interviewed the Director of Resident Services as well as attempted to interview resident R1. Resident records were requested, obtained and reviewed during the visit. Incident reports regarding resident R1 and submitted by the facility to the Department were reviewed. A follow-up facility visit was conducted on February 27, 2023. Additional records reviewed. Executive Director and Memory Care Director interviewed. Resident was transferred to Newport Beach Senior Care III (facility #306004302) and passed away there on November 3, 2022. Admission records and hospice records were also reviewed and additional interviews conducted by LPA. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099-A Regarding the allegation that Facility staff did not keep accurate records on resident(s), the following was concluded: LPA obtained records initially transmitted to the family of resident R1 by facility staff that were shown to include unrelated documents pertaining to resident R2 and R3 that had been included erroneously. The allegation is therefore deemed to be Substantiated, meaning the preponderance of evidence standard has been met. A citation is issued on an attached form LIC9099-D, An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Facility staff did not ensure that resident was adequately dressed, Facility did not have sufficient staff to meet the resident's needs, Facility staff did not assist resident to the restroom, the following was concluded: Due to the evolution of resident R1's condition, increasing difficulties with mobilization and transfers were documented by the facility in an attempt to demonstrate the need for a higher level of care. However, a majority of interviews conducted, observation led and records reviewed did not corroborate the fact that the facility was ever negligent in providing care and supervision to the resident. Therefore, the allegations that Facility staff did not ensure that resident was adequately dressed, Facility did not have sufficient staff to meet the resident's needs and that Facility staff did not assist resident to the restroom are deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided and left at the facility. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility staff mismanaged resident's medications (resident was overmedicated), the following was concluded: Based on a review of prescriptions, nursing notes and interviews conducted, it was confirmed that the medication received by resident R1 was based on prescriptions by either the primary care physician or the hospice physician which no prescriptive input from facility staff. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Facility did not give resident a 30 day notice, the following was concluded: Multiple care conferences were initiated by facility staff to inform resident R1's family that the resident's condition had evolved to become incompatible with the care and supervision being provided at the facility. However, the resident's transfer to a different facility was consensual and no orders for an eviction were issued due to no eviction being initiated. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Facility staff did not ensure that resident was adequately hydrated, records of medical examination dated October 4, 2022 by the hospice physician were obtained and reviewed during the investigation. Report states clearly that no signs and symptoms of dehydration were present in resident R1. The allegation is therefore found to be unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Facility bathrooms do not provide a safe environment for residents in care (no support commode frames, grab bars) and that Facility bathrooms did not have supplies (soap, paper towels, toilet paper), the following was concluded: During facility visits conducted on October 11, 2022 and February 27, 2023, LPA conducted a tour of several units in the memory care wing of the facility and observed both the presence of grab bars and non-slip surfaces as well as hygiene supplies stored under lock due to the presence of dementia residents. The allegations are therefore found to be unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 22-AS-20221006125126

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: Apr 2, 2023

The California Code of Regulations Section 87506(c) states that: "All information and records obtained from or regarding residents shall be confidential." This requirement was not met as evidenced by: Based on a review of records conducted by LPA, documents pertaining to residents R2 and R3 were erroneously submiited alongside communications with the family of resident R1. This constitutes a potential risk to the health,. safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: Licensee to conduct an audit of existing resident files to ensure confidentiality compliance before the Plan of Correction due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Maintenance Director Adam Alvarado and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. The purpose of today’s visit is to follow up on an investigation conducted by the Department. The investigation conducted revealed the following: Resident 1 (R1) was admitted into the facility on 08/08/2022 and was assessed to be independent of all activities of daily living except for medication management. Resident had been living independently prior to moving to facility but had difficulties with medication management resulting in the resident’s placement at facility by R1’s family. R1’s pre-appraisal dated 08/02/2022 indicated R1 was independent of care and had a diagnoses of Parkinson’s Disease. R1 had a noted history of hallucinations due to inconsistency of taking their Parkinson’s medication. Per the appraisal, when R1 is taking prescribed Parkinson’s medication as prescribed, R1 is considered mentally stable with no hallucinations. At the time of admission, R1 was believed to have been stabilized with no current hallucinations. R1’s physician report dated 08/04/2022 confirms the history of Parkinson’s related hallucinations, depression, and anxiety along with a diagnosis of Mild Cognitive Impairment. During the assessment process, staff spoke with family regarding the depression diagnosis and family stated it was mostly historical as R1 had suffered from depression since early childhood. R1 was not exhibiting any signs of distress through the admission process. On 08/14/2022, R1 verbalized to staff that they wanted to disappear. Staff believed the statement was reflective of the resident being new at the facility and adjusting to the new surroundings. R1 was observed during the week periodically coming into the dining room to eat and staff reported no concerns had been observed. Resident had been eating in their room, per the resident’s preference, when not in dining room. Staff had seen no other concerns with the resident. On 08/16/2022, Staff 1 (S1) reported they went to R1’s room CONTINUED ON LIC 809C DATED 02/17/2023 around 7:45 AM to check on the resident as resident had not come down for breakfast. Upon entry, S1 observed R1 lying on the loveseat in their room with a purple bag wrapped around R1’s head. R1 was cold to the touch and appeared to be unresponsive. 911 was called and Newport Beach Police responded. R1 was declared deceased and the Deputy Coroner arrived to examine the body. The Coroner determined there was no other trauma present on the rest of the resident’s body. R1 had been residing in the assisted living and facility checks were not required, per facility protocol, due to R1 being independent of activities of daily living. However, all staff interviewed confirm resident was being frequently checked on as the resident was acclimating to living at the facility. Interviews conducted reported R1 was last checked on at approximately 8 PM on 08/15/2022 at which time staff did not suspect any indication of suicidal ideation. R1’s death certificate was issued by Orange County Coroner’s office with an immediate cause of death listed as Asphyxiation with plastic bag over head. Based on the investigation, there is no evidence to determine lack of care and supervision resulted in R1’s death. Therefore, the allegation was determined to be unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 17, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management visit to follow up on an incident report received by Community Care Licensing on 01/30/2023. LPA identified herself and discussed the purpose of the visit with Executive Director (ED) Johanna Gonzalez. Incident report dated 01/27/2023 indicated that on 1/22/2023 at 4:00 PM, MedTech was on her way to give medication to Resident 1 (R1) when she found out that R1 wasn't inside R1's room. Later MedTech was informed that R1's son, took R1 to ER for leg pain...R1's son informed community on 1/26/2023 that R1 sustained a fracture on pelvis and will be staying a few months in a Skilled Nursing Facility. LPA Martinez reviewed R1's file, reviewed and obtained copies of Guest Sign In sheet for 01/22/2023; and R1's MAR for 01/2023. ED Gonzalez is unable to state when R1 was picked up by son. R1's sons name is not found on Sign in sheet for 01/22/2023. MAR shows R1 was given AM and afternoon medication on 01/22/2023. Also provided was a copy of Meal Attendance Report that shows R1 ask for Tray service for breakfast and lunch. R1's son picked up R1's belongings on 1/31/2023 and indicated R1 will not be returning to the facility. Facility to gather detailed information on incident and forward to LPA Martinez by close of business day of 2/6/2023. Further follow up is needed. LPA Martinez will return at a later date to continue follow up on this incident. No deficiencies cited at this time. Exit interview conducted and a copy of this report will be sent to email on file.the state’s words, verbatim · CDSS document, Feb 2, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced case management visit to follow up on an incident report submitted on 10/03/2022 to the Department. LPA identified himself and was greeted and and granted entry by Executive Director Johanna Gonzalez after explaining the purpose of the visit. An incident report and a Report of Suspected Dependent Adult/Elder Abuse (Form SOC341) both dated 10/03/2022 indicate that on 09/29/2022 at approximately 5:00pm, Resident 1's sister reported $600 missing from R1's purse. Newport Beach police department was called and a case was created under reference number #2209290163. Officer said this is being documented only at this time. R1's sister was in the community when the officers were called. Executive Director states that no other similar complaint have been recorded at this time. Resident has frequent outside visitors and facility has no suspicion on a potential perpetrator. Family was advised to avoid leaving large sums of cash in the resident's bedroom. LPA interviewed resident R1 privately in the facility's library to gather their account of the incident. No citations noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 11, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 08/26/2022. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 08/25/2022 indicated Resident 1 (R1) advised home health nurse that the resident had been touched inappropriately. 911 was called and Newport Beach Police responded and took a report. R1 indicated that it was a male resident who followed the resident to the resident's room. R1 states telling the male resident to stop, which the resident did, and left the room. Facility conducted an investigation but were unable to determine who the male resident might have been due to a lack of information provided by R1. R1 was put on escorting for two weeks to ensure nobody was following the resident. During the visit, LPA spoke with R1 who verbalized no concern after the situation as well as feeling safe in the community. Per physician report dated 03/26/2021, R1 is fairly independent with facility providing medication management only. No further action required. No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 6, 2022

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and pre-placement appraisal. Regarding the allegation of Unlawful Eviction, the investigation revealed the following: Resident 1 (R1) was sent out to Hoag Hospital on 08/03/2022 for an evaluation related to an aneurysm. While hospitalized, R1 had a permanent tunneled port catheter inserted in the chest for Dialysis treatment. This is a prohibited condition per Title 22 regulations. Facility indicated to R1's family that resident could return to the facility but only with a 24 hour nurse to oversee the port catheter due to R1's Dementia diagnosis which the family declined. R1 was moved out of the facility by resident's family on 08/13/2022. Therefore, the allegation is deemed UNFOUNDED, meaning the allegations is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Aug 16, 2022 · control 22-AS-20220812121139

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. At 8:05 AM, LPA received a voicemail from Administrator for a return call. LPA did not respond as was en route to the facility. When LPA arrived there were multiple law enforcement vehicles outside the facility. LPA entered and was notified that Resident 1 (R1) had been found by staff deceased by self inflicted injury in the resident's room around 7:45 AM. Coroner was on-site as well. Resident 1 admitted into the facility on 08/08/2022 with a diagnosis of Parkinson's Disease complicated with delusions, insomnia, anxiety, depression and anorexia along with Mild Cognitive Impairment. R1 had previously been living in independent living in another location. R1 is independent of any assistance with activities of daily living and was last observed by staff around 630 PM on 08/15/2022. Resident had not been observed to have any behaviors or suicidal ideations since admitting into the facility and was acclimating well and participating in activities and dining. R1's family was actively involved in resident's life and had been visiting the resident since admitting into the facility. LPA attempted to observe the resident's room but room was sealed off per Newport Beach Police Department. During the visit LPA toured the facility and observed residents participating in activities as well as relaxing in common areas. No health or safety violations noted during today's visit. Based on the observations made during today's visit, no violations noted. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 16, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports received by Community Care Licensing. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 07/18/2022 indicated Resident 1 (R1) was found right outside the facility gate near the gas station neighboring the facility. R1 was redirected back into the facility with no adverse effects. Resident is a new admit to the facility and had been living at the facility for only a few days. Resident moved into the facility after living independently in own home and driving. Facility investigation revealed that the resident had come to the front desk wanting to leave but was redirected. R1 went into the movie theater to relax. Reception went to check on the resident a few moments later and the resident was not there. Reception put out a page to staff to check in room and reception went outside where the resident was observed. R1 may have gone out a back door which is unlocked and opens into the front of facility where R1 was found. Facility put a one on one companion with resident until results of a urinalysis come back. Physician report dated 07/13/2022 indicates R1 has a diagnosis of Dementia and is unable to leave the facility unassisted. Incident report dated 07/07/2022 indicated R2 was sent out to Hoag Hospital after verbalizing suicidal ideations. Resident returned to the facility with no medication changes and cleared by physician. Resident has not had any prior suicidal ideations or since then and states the resident was just frustrated that day. Physician report dated 04/22/2022 indicates a diagnosis of Mild Cognitive Impairment and no diagnosis of any mental health issues. During the visit, LPA met with both residents who verbalized satisfaction with the facility and felt safe at the facility. Both appeared clean and well taken care of. No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 21, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident reports/ SOC 341 received by Community Care Licensing. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 05/13/2022 indicated that a private aid reported smoke coming from Resident 1's (R1) room. Code red initiated and maintenance responded. R1's microwave was on fire. Maintenance cleared the fire with a fire extinguisher. No injuries noted on R1. Resident to be re-assessed and microwave was removed. R1's physician report dated 03/19/2019 does not indicate any cognitive decline and resident is able to manage own medications. Incident report/ SOC 341 dated 05/16/2022 indicated R2 had entered R3's room uninvited. R3 called out for help and when staff responded R3 was observed hitting R2 with a clothes hanger. R2 was redirected out of the room and noted to have redness on the hand with no open injury. Residents do not recall the incident. R2 was sent for a urinalysis with results pending. Both residents reside in the memory care unit. During the visit, LPA toured the memory care unit and observed both residents who appeared safe and well taken care of. No deficiencies noted during today's visit and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 18, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report/ SOC 341 received on 02/07/2021. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Soc 341 indicated that Resident 1 (R1) reported that an agency caregiver spoke to the resident in an inappropriate way. Facility notified the agency and advised that the staff (S1) would not be allowed to return to the facility. Newport Beach Police were called but R1 refused to speak with them. During the visit, LPA spoke with R1. R1 refused to disclose the inappropriate comment made by S1. R1 verbalized feeling safe in the community as well as satisfaction with facility caregivers. No further investigation required. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Johanna Gonzalez has a current administrator certificate expiring on 01/18/2023. At 10:10 AM, LPA toured the facility with Administrator Gonzalez. Facility has 86 residents in care during today's visit with 5 residents on hospice care. Facility consists of 71 residents in Assisted Living and 15 residents in Memory Care. LPA observed a library, activity room, salon, and fitness center. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are a combination of single and double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes an electronic sign in/ questionnaire sheet. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed multiple outside visitation areas. LPA observed the medication room and facility uses electronic medical records for medication management. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files are up to date including emergency information. Most residents and all staff are vaccinated for Covid-19. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 23, 2022

Allegation investigated: Facility is wrongfully evicting Resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. During the course of the investigation, LPA interviewed staff and resident as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegation that facility is wrongfully evicting resident, the investigation revealed the following: On 11/07/2021, Resident 1 (R1) eloped out of the facility with three other residents to go for a walk. The residents were observed on the front patio of facility by staff and redirected back into the facility. Per physician report, R1 is unable to leave the facility unassisted. R1 is diagnosed with Dementia. Facilty staff advised R1's responsible party that R1 would need to be moved into a memory care unit due to the elopement and documented decline. Facility memory care unit does not have any current openings and responsible party was given options at other Atria facilities that have openings. Family declined those options and R1 was put with a one on one caregiver until the resident could be admitted into a memory care. Facility does not utilize wander guards. CONTINUED ON LIC 9099C DATED 11/22/2021 Unfounded Executive Director as well as Resident Services Director both deny giving out any timeline for relocation or a written eviction notice. Both state advising responsible party prior that R1 was declining and would have to be moved to a memory care unit at some point. Facility documentation confirms those conversations. Responsible party confirms not receiving an eviction notice from the facility. Therefore, the allegation is deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 22, 2021 · control 22-NP-20211112125130

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report dated 11/07/2021. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 11/07/2021 indicated four residents had wanted to go for a walk. The residents exited the exit gate at the front of the property and walked onto the front patio of the facility. Facility staff observed the residents and redirected back inside the facility. All four residents are unable to leave the facility per physician report. Residents were re-assessed and two are being referred to the memory care unit. During the visit, LPA observed three residents participating in activities and spoke with two of the residents who verbalized feeling safe and cared for at the facility. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 16, 2021

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing (CCL) on 10/18/2021 and 10/26/2021. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 10/17/2021 indicated that Resident 1 (R1) was found on the roof of the community. R1 had crossed over via the roof top terrace. R1 was on edge of roof stating wanting to end the resident's life. 911 was called and first responders were able to safely remove resident from roof. R1 was transported to Hoag Hospital and placed on a psychiatric hold. R1 remains hospitalized to date. Physician report dated 07/23/2019 indicates R1 has a diagnosis of Major Depressive Disorder and was receiving psychotherapy. This is R1's second attempt to end the resident's life. R1 is currently prescribed Latuda 80 mg for Bi-Polar and Quetiapine Fumarate 25mg for Major Depressive Disorder. Upon discharge from hospital, R1 will be re-evaluated for suitability in the facility. During the visit, LPA, toured the roof top terrace and observed the area the resident was found. R1 moved a patio table to the wall and hoisted up over the wall. The wall was observed to be high and not easily accessed. Facility to keep LPA informed regarding R1's admission back into the facility. Incident report dated 10/25/2021 indicated two residents got into an altercation. R2 approached R3 stating the resident was going to put arsenic in the resident's coffee. R3 became frightened and grabbed a butter knife to intimidate R2. Staff intervened and the two were separated. No contact was made between residents and no injuries noted for either resident. Newport Beach police were called and declined to take a report due to the nature of the incident. No further action required. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 27, 2021