Newport Mesa Senior Living.

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to the facility to conduct a health and safety check for an incident that was reported to the Regional Office. LPA explained reason for visit and was greeted by staff on duty. On October 13, 2025, the Regional Office received an incident report of elopement with the incident occurring for October 05, 2025 for resident 1 (R1). R1 exited the facility at approximately 10:34am on that day. Staff was made aware R1 was not at the facility and initiated search and safety protocols at 11:30am. R1 was located by local law enforcement and brought back to the facility at approximately 3:30pm the same day. The facility's main entry and exit door is in the process of repair and has partial functionality. Temporary measures haven taken place to alert staff when the door is open including an audible alarm that will alert every time the door is open regardless if the door is armed. LPA tested the egress function and it is operational. The facility held in-service training for staff on September 9, 2025, October 3, 2025, and October 6, 2025 on updated protocols for elopements. Facility provided updated elopement policy along with R1's records to LPA. Executive Director Melvin Galloway stated the facility will complete an ongoing remodel by mid November which includes replacing the main door's electronics to restore full functionality. LPA toured the facility and observed no health or safety concerns. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 05/21/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the visit. LPA toured the facility to check the deficiencies have been corrected with staff. Water temperature in the bathroom by room 8 measured 126.5 degrees F, higher than previous reading of 89.9 degrees F during the annual inspection. LPA observed one signal system button installed in one room and one signal system button being carried by a resident. The plan of correction for two citations were not completed by the due date. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 40 non-ambulatory residents of which 15 may be bedridden. Facility has an approved hospice waiver for 15 residents. Administrator (AD) Rose Nakadaira arrived shortly to facilitate visit. AD provided updated liability insurance that expires on 06/01/2025. LPA along with staff toured the facility at 9:30 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility consists of 22 resident bedrooms, living areas, dining room/activities room, prep kitchen and full kitchen as well as 8 shared resident bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed there is no resident signal system in the resident bedrooms. At 10:30am, LPA observed missing smoke alarm in room 19. Resident bathrooms were checked. Toilets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 89.9 degrees F and 119.8 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 9:50 am, LPA observed fruit flies hovering in the prep kitchen next to the activities room. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the full kitchen. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Outside grounds were toured. Walkways around the facility were clear of hazards. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. Continued on LIC809-C dated 05/21/2025 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed the emergency food and water supply. LPA reviewed five resident files and five staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cart. Medications are being administered per physician order. Facility did not have fire system maintenance records dated within the last 12 months. Facility did not have records of emergency drills occurring within the last 3 months. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.

Two of eight staff stated that S1 has a history of being out of compliance at work and not following directions. Interview with kitchen staff confirmed that facility has a binder for residents who have special diets that gets updated when changes are made. Based off records review, an incident report dated 10/11/2024 states that R1 was fed eggs by S1 and aspirated. Incident Report states that 911 was called and resident taken to hospital. Narrative Charting notes dated for 10/15/2024 stated that R1 was aspirating during dinner, 911 was called and paramedics arrived and suction R1. Record review of menu for October 11, 2024 for breakfast was Sausage Link, choice of cereal, pancakes and choice of juice. Menu did not match what witness reported R1 eating that day. Staff Schedule does confirm that S1 was working AM shift on October 11, 2024. Residents Physician’s Report dated 9/6/24, Preplacement Appraisal dated 9/9/24, and Needs & Service Plan dated 9/13/24 all state that R1 has a pureed diet with thickened liquids, water and Juice. Needs & Service plan states that “Residents goals for meals are to maintain adequate nutritional intake and allow enough time for resident to eat at a comfortable pace”. Preplacement Appraisal states under services needed, resident has special diet and observation of food intake. Collective Hospice Care Documents Revealed that R1 was admitted under Hospice Care on 10/16/2024. During initial visit on 10/30/2024, during facility tour LPA Tirre observed the following during visit: LPA reviewed Board in Kitchen with names of residents on special diets and observed that R1 was missing from board. LPA also attempted to view kitchen binder that has special diet orders for residents and was informed that a staff member borrowed binder and had not returned. LPA observed R1 to be sleeping in bedroom during visit and was unable to interview. Based on interviews, records reviewed and observations the preponderance of evidence has been met, deeming the allegations Facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided is deemed SUBSTANTIATED. The following deficiencies are being cited per Title 22. A exit interview was conducted with Executive Director Rose Nakadaira. A copy of this report, confidential names list and appeals right was provided to facility.

It was alleged that a resident was prescribed a medication to be taken every day for 21 days, but was only given the medication for three days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating the allegation. LPA inspected the medications for these 10 residents and noted no medication errors. However, LPA reviewed the Medication Administration Records for these 10 residents and noted that all 10 residents have missed doses of medications in the last three months due to the medications not being in stock at the facility, including medications for blood pressure and heart conditions. Per AD, reasons for these medications not being in stock at the facility include residents’ families not bringing in the medications and doctors not timely providing refill prescriptions before the medications ran out. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 It was alleged that a resident sustained an injury at the facility, received stitches and needed their bandages changed daily, but the bandages were not changed for over three or four days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating any unsafe conditions, lack of medical treatment, or issues regarding care and supervision. LPA reviewed recent wound care records which showed that the most recent wound at the facility was properly treated and had healed. Interviews with AD and staff revealed that the facility is properly identifying residents with wounds, ensuring they receive proper wound care, and ensuring wound care is properly documented. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Liam Larson who greeted LPA and assisted with the tour of the facility. At 10:00 AM the Administrator Rose Nakadaira arrived at the facility and she was informed of the purpose of the visit. Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature was tested throughout the facility which was within regulation 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins,and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. LPA also observed emergency food supply and water. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians. LPA also reviewed Three (3) staff files for First Aid/CPR certification, annual training's, health screenings and the files reviewed were not complete/current. Based on LPA's observations a citation was issued for not having the staff files current. An exit interview was conducted, and this report was discussed and provided to Administrator Rose Nakadaira at the conclusion of the visit.