Atria Newport Plaza

Allegation investigated: Staff did not provide adequate supervision Staff did not ensure resident received medical care as needed

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation visit. Upon arrival, LPA met with Executive Director Johanna Gonzalez and explained the purpose of the visit. It was alleged that “Staff did not ensure resident received medical care as needed” and “Staff did not provide adequate supervision.” The complaint stated that Resident 1 (R1) was found unresponsive on the bedroom floor on December 30, 2025. Emergency medical personnel transported R1 to the hospital. The complaint further stated that R1 was diagnosed with an influenza infection, cardiac arrest, and brain death and was later pronounced deceased at the hospital. The reporting party (RP) alleged that the facility did not ensure R1 received an influenza vaccination and did not complete required 30-minute room checks, resulting in delayed medical intervention. During the investigation, LPA interviewed four staff members. Four out of four staff members denied the allegations and stated that residents receive appropriate supervision and that staff obtain medical assistance when a resident exhibits a change in condition or requires medical attention. Staff members stated that residents in the memory care unit are checked approximately every two hours. However, the facility does not maintain written records documenting the completion of these routine checks. LPA also interviewed four residents. {CONTINUE 9099C} Unsubstantiated Four out of four residents denied that staff failed to provide adequate supervision or necessary medical care and stated that staff were available and responsive to their care needs. LPA reviewed facility records for R1. The records documented that R1 was admitted to the facility on December 10, 2021. An updated Physician’s Report dated May 23, 2024, indicated that R1 had dementia and was subsequently relocated to the facility’s memory care unit. Facility documentation also reflected that influenza and COVID-19 vaccinations were offered at the facility on October 29, 2025, however, no records showed that R1 received any vaccination. LPA interviewed R1’s Power of Attorney (POA), who is also R1’s son. The POA confirmed that R1 was offered an influenza vaccination but could not recall whether R1 received the vaccination. The POA further stated that the facility did its best to care for R1 and that he was satisfied with the care and services provided by the facility. LPA also reviewed an email communication dated January 3, 2026, between the facility and the POA. In the email, the POA thanked the facility for caring for R1 and expressed appreciation for the care provided following R1’s passing. LPA attempted to contact the RP on April 23, 2026, April 27, 2026, and July 10, 2026. LPA was unable to obtain a statement from the reporting party. Based on interviews conducted and records reviewed, there was insufficient evidence to establish that staff failed to ensure R1 received necessary medical care or failed to provide R1 with adequate supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations are deemed Unsubstantiated.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 22-AS-20260420152314

Type of visit: Required - 1 Year

On today's date LPA's William Vanegas and Brandon Lopez conducted an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry to the facility by staff after explaining the purpose for the visit. Administrator (AD) Joanna Gonzalez was present and assisted on today;s visit. LPAs observed that AD Joanna Gonzalez has a valid Administrator certificate which expires January 18, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for 160 residents, all of which can be non-ambulatory, and has a hospice waiver for 25. The facility consists of a single building that is three stories tall. The building consists of private apartments that contain bathrooms located in the apartments. A commercial kitchen, a dining room, a wellness center, a salon, laundry rooms, medications rooms, activity rooms, and storage rooms. LPAs accompanied with AD conducted a tour of the interior portions of the faciltiy. LPA's observed the PUB 475 and all other required postings to be posted at the entrance of the facility and visible to all guest and residents in care. LPAs observed a total of 10 resident apartments. LPAs observed resident apartments to have all required items such as a bed, clean linens in good repair; meaning no strains or tares, chest drawers, a chair, a reading lamp, and a storage space for personal belongings. LPAs observed residents to have a pendant with them to call for assistance. Pendants were pressed and tested operational. LPAs inspected resident bathrooms and they all appeared to be clean and free of any mildew or debris. Toilets and water faucets tested operational and water tested between 110.1 and 120.2 degrees. Showers were observed to have slip resistant floors, grab bars, and a shower chair. CONTINUED ON LIC 809C LPAs observed the facility to have a minimum of two day perishable and seve day non-perishable food supply on hand LPAs observed the facility has a three day emergency food and water supply kept in a storage room. LPAs observed multiple fire extinguishers that were fully charged and up to date. LPAs observed evacuations chairs that are accessible in each stairwell. LPAs observed that the facility had their most recent fire inspection conducted on August 18,2025. LPAs observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPAs observed the centrally stored medication to be kept in locked medicine carts located in the medication room. LPAs observed first aid kits to be stored in each of the medication rooms and they had all the required components. LPAs observed all the facilitys chemicals and toxins to be stored in a locked storage room. LPAs observed other common areas such as the dining rooms, staff offices and activity areas to be clear of any hazards. LPAs accompanied with the AD, conducted a tour of the exterior portions of the facility. LPAs observed an outdoor shaded sitting area with furniture for residents to use. LPAs observed the exterior to be free of any hazards. LPAs tested the delay egress doors located on the exterior portions which tested operational. LPAs reviewed the 10 resident files. All the required documentation was present and current in each resident file. LPAs reviewed residents medication and medication administration records. LPAs reviewed 10 resident files as well. All required training and first aid and CPR were present and current. Based on the observations made during today's visit no deficiencies are being cited per title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Johanna Gonzalez and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2026

Allegation investigated: Staff did not reappraise resident when his condition changed. Staff did not provide resident's authorized person sufficient notice before changing his basic needs and services plan. Staff kept resident isolated in his room. Staff did not provide adequate care or supervision for residents to prevent falls. Staff accepted a resident that required a higher level of care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the five allegations listed above as well as to deliver findings to the licensee. LPA was greeted and granted entry by the facility's front desk staff after stating the purpose of the visit. Administrator Johanna Gonzalez was present and assisted with the visit. The initial complaint investigation visit was conducted on March 4, 2025. LPA accompanied by facility staff conducted a tour of the facility's memory care. Resident records were requested and obtained. A total of six staff interviews were also conducted during the visit.Additional witness interviews were conducted during the investigation along with additional records gathered. During the present visit, LPA requested R1's admission agreement for review and conducted a tour of the memory care unit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not reappraise resident when his condition changed, the following has been concluded. Resident R1 was assessed upon move-in in October 2023 and was then reassessed multiple times throughout the period of admission, with assessments reviewed for April 2024 after six months, then monthly after July 2024 once the resident was moved to the facility's memory care until R1's move-out in December. Gradual updates appear to reflect the evolution of R1's cognitive and behavioral abilities. Regarding the allegation that Staff did not provide resident's authorized person sufficient notice before changing his basic needs and services plan, the allegation is based on facility staff ordering the immediate implementation of a one-on-one caregiver starting on December 5, 2024. Per R1's admission agreement signed by all parties on September 27, 2023, the resident and their responsible party had agreed to a clause stating: "If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk, and we will communicate that decision to someone on your behalf according to the Responsible Party and/or Emergency Contact information you agree to provide us. This communication will occur in advance of implementing a private duty caregiver, if reasonably possible, or soon after we have made the decision regarding your safety". Multiple incidents involving aggressive behavioral expression were reported to the responsible party as well as to the resident's primary care physician prior to the December 5 notification. Additionally, one-on-one supervision is not listed among the basic resident services for which a change in rate would require advance notice. Regarding the allegation that Staff kept resident isolated in his room, the following has been concluded: During both facility visits, licensing staff toured the memory care unit. During both visits, residents appeared free to ambulate, with no residents found to exhibit any signs of distress. Residents were observed relaxing in the unit's common area or in their respective bedrooms. Staff interviews evidenced that one of the recommended redirection strategies for some of R1's behavioral expression was to accompany the resident back to their unit to allow R1 to calm down as well as to avoid disrupting care for the other memory care residents. Interviews however did not provide sufficient evidence to corroborate that R1 was kept in their bedroom against their will. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff did not provide adequate care or supervision for residents to prevent falls, the following has been concluded: R1 sustained multiple fall incidents during their admission at the facility. Multiple assessments reviewed show that the resident was identified as a fall risk upon admission. R1 sustained scalp lacerations as a result of a fall that occurred on a family outing in May 2024, as well as skin abrasions as a result of an unwitnessed fall in memory care. Two other falls occurred prior to R1's relocation to memory care and involved mobility in the facility's elevator. Such incidents did not recur after the resident moved to the unit located on the ground floor. Interviews and records reviewed did not evidence any failure to provide adequate care and supervision of a nature that would result in a fall. Regarding the allegation that Staff accepted a resident that required a higher level of care, the following has been concluded: Allegation was formulated regarding former resident R2, admitted on October 5, 2023 upon the basis of a pre-admission assessment dated September 29, 2023. Initial assessment was confirmed in the days following the move into the facility. R2 however declined rapidly and was reassessed to a higher needs profile on October 10, 2023, before being placed onto hospice care on October 12. R2 passed away with hospice present at bedside on October 14, 2023. However no elements of R2's assessment or physician report appear to indicate the resident would not have been appropriately placed at the facility or would have required continuous nursing care at the time of admission. R2 also appears to fit the criteria for acceptance and retention listed as Attachment D of their residency agreement. As a result of the evidence gathered during the investigation, all five allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, May 28, 2025 · control 22-AS-20250224150154

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPA) Kevin Saborit-Guasch and Hanna Gough made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry after introducing themselves and the purpose of the visit to front desk staff. Executive Director Johanna Gonzalez was notified of the visit via telephone and could not assist with the visit in person. Licensing staff received the assistance of Business Office Director Karla Arteaga. LPAs requested and reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, COVID-19 Mitigation Plan. Infection Control Plan is not present. Technical Violation Advisory Note provided along with a copy of licensing form LIC9828. A sample of nine staff records and eleven resident records were reviewed during the visit. There are 111 residents admitted at the time of the visit, five of which are receiving hospice care. 14 of these 111 residents are admitted to the Memory Care unit. Resident and staff records were confirmed to include all necessary components per Title 22 regulations. All staff members are confirmed to have adequate background clearance and association status in Guardian. Proof of training were provided and confirmed staff members met the minimum initial and annual training requirements. Facility is a three story building with 112 resident rooms. Resident rooms are on all three floors. Memory care is on the first floor and has 12 rooms. The third floor is approved for ambulatory only. All residents records reviewed for the third floor confirmed residents ambulatory status. LPAs accompanied by facility maintenance staff conducted a tour of the interior and exterior of the physical plant. A total of eleven units were visited and reviewed throughout the facility. Rooms were observed to be equipped with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floors and/or tiling. Hot water was measured in a total of twelve locations at faucets delivering hot water for grooming purposes. Water was systematically observed to be within the acceptable temperature range. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPAs and staff additionally toured the facility kitchen. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Emergency food and water supply observed in the facility's food storage. Medications, cleaning supplies, and sharp items were inaccessible to residents in care in the memory care unit. Memory Care kitchen was reviewed for dangerous items, all of which are secured in locked cabinets. LPAs reviewed the physician orders and contents of two of the facility's medication cart. Memory care medication cart was additionally verified to be locked when not attended. One resident whose records were reviewed was determined to have been assessed to be unable to manage their self-administered medication. Resident is verified to be on Medication Management per review of the electronic Medication Administration Records. However prescription ointments and over-the-counter supplements are observed in the resident's bathroom during the walk-through. Type B citation issued. Sprinkler system and fire safety systems were inspected respectively in September and August 2024 with no deficiency or disfunctional equipment noted. All mounted fire extinguishers throughout the facility are confirmed to be fully charged. Carbon monoxide detectors are located in multiple locations on each of the three levels. For the exterior portion, facility has a central courtyard with a patio. The second level has a balcony with sturdy railing above the inside courtyard. Finally, there is a rooftop outdoor area with ample outdoor furniture and shade on the facility's top level. The memory care unit has a separate courtyard with secure egress, furniture and shade also which is accessible through multiple doors leading out of the unit. Delayed egress is in place as approved in the facility and ample quantity of outdoor furniture and activity materials are present. Activities are observed to be in progress in the memory care during the walk-through. The routes of egress were free of tripping hazards and the exit gates were self-latching and functional. Licensee agreed to submit proof of liability insurance via email at the earliest convenience. One type B deficiency is cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jan 13, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director Johanna Gonzalez and explained the reason for the visit. LPA observed the See Something, Say Something poster (PUB 475) posted in the entryway of the facility. The Executive Directors Administrator's Certificate expires January 18, 2025. Facility is a three story building with 112 resident rooms. Resident rooms are on all three floors. Memory care is on the first floor and has 12 rooms. The memory care unit has 2 delayed egress exits that are operational. Facility has a capacity for 160 non-ambulatory residents. The third floor is approved for ambulatory only. Hospice waiver is approved for 25 residents and no bedridden. LPA and the Executive Director toured the facility. LPA observed that all fire extinguishers throughout the facility are fully charged. The memory care unit is secured and requires a code to enter. The memory care unit has a dining room and activity room. LPA observed that all resident rooms in memory care had the required furnishings and bed linens. No obstacles or hazards observed in the memory care unit. LPA observed that there is an emergency evacuation chair at the top of each stairwell. LPA observed that in the 7 resident rooms inspected in assisted living, all the rooms had the required furnishings. LPA observed that all resident bathrooms that were inspected were clean and operational. Hot water in the bathrooms inspected measured from 107.0 degrees Fahrenheit to 112.4 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed the temperature logs are posted on the refrigerators. LPA observed there is a 2 day supply of perishable and a 7 day supply of non-perishable food on hand in the kitchen. Both the memory care unit and the assisted living section have outdoor patio areas with shade for the residents to sit outside. No obstacles or hazards observed in the assisted living section of the facility. LPA observed the emergency food and water is stored on the third floor in a storage room. LPA interviewed staff and residents. LPA reviewed 10 staff files. No discrepancies observed. The 7 care staff files reviewed had the required training documented. LPA reviewed 10 resident files, no discrepancies noted. LPA reviewed resident medications, no discrepancies noted. The last fire drill was conducted on April 19, 2024. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided to the Executive Director.the state’s words, verbatim · CDSS document, Apr 24, 2024