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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004640
Report Date: 06/04/2026
Date Signed: 06/04/2026 04:00:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251208162553
FACILITY NAME:NEWPORT MESA SENIOR LIVINGFACILITY NUMBER:
306004640
ADMINISTRATOR:ROSE NAKADAIRAFACILITY TYPE:
740
ADDRESS:2891 BEAR STTELEPHONE:
(949) 629-1020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:40CENSUS: 19DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Melvin GallowayTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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Staff did not ensure the residents were administered their medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff do not ensure the residents were administered their medication. LPA conducted interviews with staff. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff did not ensure the residents were administered their medication, it was reported medications are not being administered per physician's orders. Interviews with four out of eleven staff stated on December 7, 2025, medications were given to residents late because there was no staff available to administer resident medications. Resident 2 (R2) called Costa Mesa PD to report no one provided their medications. Costa Mesa PD arrived at the facility. The police officer called Staff 1 (S1) to have them return to the facility to assist with administrating medications.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20251208162553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT MESA SENIOR LIVING
FACILITY NUMBER: 306004640
VISIT DATE: 06/04/2026
NARRATIVE
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Interview with S1 stated they were called by a police officer to make them aware there was no one available to administer medications. S1 stated they arrived at the facility at 8:45pm that day and finished passing medications at 9:30pm. One out of the remaining seven staff stated they have observed medications on the floor during their shifts. One out of the remaining six staff stated they have observed medications in residents' hands from a previous medication pass. One out of the remaining five staff stated there are no med techs that work on weekends. Two out of the remaining 4 staff stated they have not observed residents not given their medications. One out of the two remaining staff stated they assist residents with medications as prescribed. The remaining staff did not add anything relevant to the allegation. LPA attempted to interview R2 but was unable to qualify for the interview.

LPA reviewed a copy of the Costa Mesa PD log for the incident which stated "Per caregiver onsite the med tech did not respond like they were supposed to at 1400 hours no patients recieved memory care medications she tried calling the managers but no answer was able to reach employee (S1) who said would respond with 30 min eta and give medication per (S1) this was a scheduling error on managers behalf and has not happened in the past 5 years of his employment [12/07/25 18:28:49 Unit:322]". LPA conducted medication audit for R2 during the initial visit on December 16, 2025 which revealed seven medications that were marked as administered in the facility's electronic medication administration record (eMar) were physically still present in R2's medication bubble packs for multiple days. Staff could not account for discrepancies. LPA documented the seven medications and eMar via photographs.

Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6), is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251208162553

FACILITY NAME:NEWPORT MESA SENIOR LIVINGFACILITY NUMBER:
306004640
ADMINISTRATOR:ROSE NAKADAIRAFACILITY TYPE:
740
ADDRESS:2891 BEAR STTELEPHONE:
(949) 629-1020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:40CENSUS: 19DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Melvin GallowayTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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Residents fell due to staff neglect resulting in injuries
Staff are administering nonprescribed medication
Staff left residents in soiled diapers for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged residents fell due to staff neglect resulting in injuries, staff are administering nonprescribed medication, and staff left residents in soiled diapers for an extended period of time. LPA conducted interviews with staff. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation residents fell due to staff neglect resulting in injuries, it was reported Resident 1 (R1) fell at the facility, causing an injury on their left arm. Interviews with two out of eleven staff stated R1 scratched their left arm often due to itchy skin which would lead to skin tears. R1 would continue to scratch scabs as well which continue the bleeding. One out of the remaining nine staff stated they recall R1. R1 had some falls and skin tears but is unsure if the injuries were due to the falls.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20251208162553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT MESA SENIOR LIVING
FACILITY NUMBER: 306004640
VISIT DATE: 06/04/2026
NARRATIVE
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Two out of the remaining eight staff stated if a resident falls, they will inform the supervisor. One out of the remaining six staff stated if a resident falls and is injured, they will call 911 for assistance. The remaining five staff did not add anything relevant to the allegation. Record review revealed R1 was admitted to the facility on August 27, 2025. R1's medical assessment dated August 28, 2025 indicates R1 has a skin condition of trauma to their left forearm and wrist. Resident assessment dated October 2, 2025 indicated resident was receiving wound/skin care. R1 was admitted to a skilled nursing facility (SNF) on December 2, 2025. The admission record from the SNF does not indicate any diagnosis of skin tears or trauma to the left arm. However, there is a diagnosis of pain in the left arm. LPA was unable to qualify R1 for an interview during the initial visit on December 16, 2025. LPA did observe bandages on R1's left arm. LPA did not observe any bleeding.

Regarding the allegation staff are administering nonprescribed medication, it was reported staff is administering melatonin to residents to have them go to sleep without a prescription. Four out of eleven staff stated they never observed a house stock of melatonin in the medication room. One out of the remaining seven staff stated there was a bottle of melatonin in the medication room, but it was prescribed for one resident and not given to others. One out of the remaining six staff stated they recall seeing a bottle of melatonin in the medication room. The remaining five staff did not add anything relevant to the allegation. LPA did not observe any bottle of melatonin in the medication room during the initial visit on December 16, 2025.

Regarding the allegation staff left residents in soiled diapers for an extended period of time, it was reported residents are not being changed overnight and are left soiled by the nocturnal (NOC) shift. Interviews with seven out of eleven staff stated they have not observed residents soiled for an extended period of time. Two out of those seven stated they have been informed by other staff of residents being left soiled from the previous shift. One out of the remaining four staff stated they have observed residents left soiled for an extended period of time. One out of the remaining three staff stated if they were to witness a resident soiled for an extended period of time, they would inform the supervisor. One out of the remaining two staff stated it is the lack of staffing that would cause residents to be soiled for an extended period of time. The remaining staff did not add anything relevant to the allegation. LPA did not observe any residents soiled during the initial visit on December 16, 2025.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20251208162553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NEWPORT MESA SENIOR LIVING
FACILITY NUMBER: 306004640
VISIT DATE: 06/04/2026
NARRATIVE
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Based on interviews, observations and record review, the above allegations are therefore deemed 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 the report was left with the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20251208162553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT MESA SENIOR LIVING
FACILITY NUMBER: 306004640
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2026
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care

The licensee shall assist residents with self-administered medications as needed.

The requirement is not met as evidenced by:
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Memory Care Director stated daily and weekly medication audits have been put in place. All current med techs have received training from a license pharmacist. Memory Care Director to send proof to LPA by POC due date.
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Medications for all residents were administered late due to no qualified staff being available on the evening of December 7, 2025. In addition, medication audit for R2 indicates seven medications were not given as prescribed which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6