Inspection Report Summary
Most inspections found deficiencies related to safety and care, including issues with medication administration, diet compliance, fire safety, and environmental hazards like fruit flies and malfunctioning alarms. The most recent report from October 21, 2025, substantiated a complaint about a malfunctioning door alarm that allowed a resident to exit unsupervised, posing an immediate safety risk; temporary measures and staff training were implemented. Earlier reports documented problems with hot water temperature exceeding safe limits, incomplete fire system maintenance, and missing resident signal systems, with some corrections made over time but not fully resolved by August 2025. Several complaint investigations were substantiated, particularly involving medication errors and diet management, while others, such as COVID-19 cohorting concerns, were unsubstantiated. Overall, the facility has shown some improvement in addressing deficiencies but continues to face challenges in maintaining consistent safety and care standards.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
60% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
An unannounced case management visit was conducted to perform a health and safety check following an incident report of elopement involving resident R1 on October 5, 2025.
Complaint Details
The visit was triggered by a complaint regarding an elopement incident involving resident R1 on October 5, 2025. The complaint was substantiated as the facility failed to maintain a functioning door alarm.
Findings
The facility's main entry door was partially malfunctioning, allowing resident R1 to exit unsupervised, posing an immediate health and safety risk. Temporary alarm measures were in place, and staff received updated training on elopement protocols. No other health or safety concerns were observed during the visit.
Deficiencies (1)
Failure to ensure the facility has an auditory device or staff alert feature to monitor exits on exterior doors accessible to residents at risk for elopement, evidenced by resident R1 exiting due to a malfunctioning door alarm.
Report Facts
Deficiency Plan of Correction Due Date: Oct 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Melvin Galloway | Executive Director | Provided information about the facility's ongoing remodel and door repair |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Plan of Correction
Census: 25
Capacity: 40
Deficiencies: 2
Date: Aug 19, 2025
Visit Reason
An unannounced Plan of Corrections visit was conducted to verify that deficiencies issued on August 5, 2025 had been corrected.
Findings
The Plan of Corrections was fulfilled by the assigned due dates, clearing the Type A deficiency CCR 87303(e)(2) and the Type B deficiency CCR 87303(i).
Deficiencies (2)
Type A deficiency CCR 87303(e)(2)
Type B deficiency CCR 87303(i)
Report Facts
Temperature measurement: 110.8
Deficiency due dates: 6
Deficiency due dates: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the Plan of Corrections visit |
| Keatlen Ballanes | Facility staff who discussed the purpose of the inspection and toured the facility with LPA | |
| Rose Nakadaira | Administrator/Director | Facility Administrator/Director |
Inspection Report
Plan of Correction
Census: 25
Capacity: 40
Deficiencies: 2
Date: Aug 5, 2025
Visit Reason
An unannounced Plan of Corrections Inspection was conducted to verify correction of deficiencies issued on 2025-05-21 during the required annual inspection.
Findings
The inspection found that the hot water temperature in the bathroom by room 8 was 126.5 degrees F, exceeding the maximum allowed temperature, posing an immediate health and safety risk. Additionally, only one resident living unit had a signal system installed, which poses a potential health and safety risk. The plan of correction for two citations was not completed by the due date.
Deficiencies (2)
Hot water temperature controls not maintained to regulate temperature between 105 and 120 degrees F; water measured at 126.5 degrees F in bathroom sink by room 8 posing immediate health and safety risk.
Signal system not installed in all resident living units; only one unit had a signal system installed, posing potential health and safety risk.
Report Facts
Hot water temperature: 126.5
Census: 25
Total capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the Plan of Corrections Inspection and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Rose Nakadaira | Administrator | Facility Administrator named in the report |
| Keatlen Ballanes | Facility staff met with during inspection |
Inspection Report
Plan of Correction
Census: 17
Capacity: 40
Deficiencies: 5
Date: May 30, 2025
Visit Reason
An unannounced Plan of Corrections Inspection was conducted to verify correction of deficiencies issued on 2025-05-21 during the required annual inspection.
Findings
The Licensing Program Analyst verified that some deficiencies were corrected, including replacement of a smoke alarm in room 19 and eradication of fruit flies in the prep kitchen. However, some fire system components still require replacement and water temperature in a bathroom was above acceptable levels. No deficiencies were cleared at this time.
Deficiencies (5)
Smoke alarm replacement in room 19
Eradication of fruit flies from the prep kitchen
Replacement of some components in the fire systems pending with service report due by 2025-06-04
Water temperature in bathroom by room 8 measured at 127 degrees F, exceeding previous reading and requiring correction by 2025-06-04
Emergency disaster drill scheduled for 2025-05-30 with deficiency to be cleared by end of day
Report Facts
Capacity: 40
Census: 17
Water temperature: 127
Previous water temperature: 89.9
Correction due date: Jun 4, 2025
Correction due date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the Plan of Corrections Inspection and made observations |
| Amy Kaplli | Director of Memory Care | Facility representative who granted entry and discussed purpose of visit |
Inspection Report
Annual Inspection
Census: 17
Capacity: 40
Deficiencies: 4
Date: May 21, 2025
Visit Reason
An unannounced required annual visit was conducted to evaluate compliance with licensing requirements for Newport Mesa Senior Living Facility.
Findings
The inspection found several deficiencies including missing smoke alarm in room 19, presence of fruit flies in the prep kitchen, hot water temperature below required levels, absence of a resident signal system, lack of recent fire system maintenance records, and no emergency drills conducted within the last quarter. Plans of correction were requested for all deficiencies.
Deficiencies (4)
Fruit flies hovering in the prep kitchen, no recent fire service records available, and smoke alarm missing from room 19.
Hot water in bathroom sink by room 8 measured at 89.9 degrees F, below required temperature range.
No resident signal system present at the facility.
No emergency drill conducted within the last quarter.
Report Facts
Capacity: 40
Census: 17
POC Due Date: Jun 4, 2025
POC Due Date: Jun 18, 2025
POC Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rose Nakadaira | Administrator | Facility administrator who facilitated the inspection visit |
Inspection Report
Capacity: 40
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The visit was conducted as an office meeting to verify the Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media.
Findings
The meeting confirmed that despite multiple lawsuits involving Pacifica Senior Living, there was no financial impact on the properties, residents, or staff. It was also noted that Pacifica Senior Living Management was no longer managing the communities, and there were no pending lawsuits against the operating entities.
Report Facts
Lawsuit amount: 25000000
Facility capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carl Knepler | Chief Executive Officer | Present during the meeting and provided information about lawsuits and management changes |
| Stacy Barlow | Assistant Program Administrator | Conducted the meeting to verify bankruptcy report |
| Shelly Gracce | Assistant Branch Chief, CCLD | Present during the meeting |
| Craig Lundgren | Legal Counsel, CCLD | Present during the meeting |
| Marlene Nelson | Director, Quality Assurance and Risk Management | Present during the meeting |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 40
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2024-10-23 that the facility did not ensure that modified diets prescribed by a resident's physician as a medical necessity were provided.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not ensure that modified diets prescribed by a resident's physician as a medical necessity were provided. Evidence included staff interviews, incident reports, physician's orders, and observations.
Findings
The investigation found that Resident 1 was prescribed a special pureed diet but was fed solid food by staff member S1, resulting in aspiration and hospitalization. The facility failed to ensure staff compliance with diet orders, and the allegation was substantiated based on interviews, record reviews, and observations.
Deficiencies (1)
Failure to ensure staff received training on special diets and activities of daily living, resulting in Resident 1 being fed solid food and aspirating despite a prescribed pureed diet.
Report Facts
Capacity: 40
Census: 22
Deficiency count: 1
Plan of Correction Due Date: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rose Nakadaira | Executive Director | Facility representative met during investigation and exit interview |
| Amy Kaplli | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Stacie Anderson | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 40
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that medication was not administered appropriately and that residents' care needs were not being met.
Complaint Details
The complaint investigation was substantiated for the allegation that medication was not administered appropriately, with evidence showing missed medication doses due to supply issues. The allegation that residents' care needs were not met was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that medication was not administered appropriately due to missed doses caused by medications not being in stock, posing an immediate health risk. Another allegation regarding residents' care needs not being met was unsubstantiated due to lack of corroborating evidence.
Deficiencies (1)
The licensee did not ensure 10 out of 10 residents received assistance with medications when the facility ran out of supply, posing an immediate health risk.
Report Facts
Capacity: 40
Census: 22
Deficiencies cited: 1
Plan of Correction Due Date: Mar 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Rose Nakadaira | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 26
Capacity: 40
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
An unannounced required comprehensive annual inspection was conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and operating safely with sufficient food supply and care staff. However, a citation was issued for incomplete and outdated staff personnel files, including missing First Aid/CPR certification, annual trainings, and health screenings.
Deficiencies (1)
Personnel records were not maintained current and complete, lacking required First Aid/CPR certification, annual trainings, and health screenings.
Report Facts
Client files reviewed: 3
Staff files reviewed: 3
POC Due Date: Sep 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Karen Clemons | Licensing Program Manager | Supervisor of the inspection |
| Rose Nakadaira | Administrator | Facility administrator informed of the inspection and present during exit interview |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility planned group activities without proper PPE and failed to cohort COVID-19 positive residents from negative residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper PPE use during group activities and failure to cohort COVID-19 positive residents. Evidence showed staff wore masks and residents were cohorted appropriately. The facility had COVID-19 positive staff working only with positive residents as allowed. No conclusive evidence linked the outing to increased COVID-19 cases.
Findings
The investigation found that staff wore masks during a resident outing but residents often removed masks; there was no evidence linking the outing to increased COVID-19 cases, and the facility followed cohorting guidelines by isolating residents based on COVID-19 status. Both allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 40
Census: 24
Date complaint received: Dec 9, 2020
Date of resident outing: Nov 21, 2020
Date of 10-day visit: Dec 14, 2020
Date all residents positive: Dec 21, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rosie Nakadaira | Executive Director | Met with Licensing Program Analyst during investigation |
| Stacie Anderson | Administrator | Facility Administrator providing information during investigation |
Inspection Report
Census: 25
Capacity: 40
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported to the Community Care Licensing Division on June 3, 2023, involving a resident who was unaccounted for during head count.
Findings
The facility acted appropriately and in a timely manner to address the incident. No injuries were observed, and no deficiencies were noted during the visit per Title 22 Division 6 of the California Code of Regulations.
Report Facts
Incident date: Jun 3, 2023
Incident time: 830
Resident found time: 1400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Nakadaira | Executive Director | Met with Licensing Program Analysts and provided information about the incident and staff training |
| Jael Sambrano | Momory Care Director | Met with Licensing Program Analysts during the visit |
Inspection Report
Annual Inspection
Census: 19
Capacity: 40
Deficiencies: 0
Date: Jun 25, 2021
Visit Reason
The visit was an unannounced Required 1 Year inspection to evaluate compliance with licensing regulations for Pacifica Senior Living Newport Mesa.
Findings
No deficiencies were observed during the inspection. The facility was found to be in compliance with regulations including fire safety, medication storage, staff training, and physical plant conditions.
Report Facts
Residents on Hospice Care: 4
Resident Rooms in Winter Building: 11
Resident Bathrooms in Winter Building: 4
Resident Rooms in Summer Building: 12
Resident Bathrooms in Summer Building: 4
Water Temperature Range: 107.3-112.5
Liability Insurance Expiration: Dec 31, 2021
Staff Files Reviewed: 6
Resident Files Reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Anderson | Executive Director | Administrator certificate is current |
| Rose Nakadaira | Business Office Manager | Met with Licensing Program Analyst during inspection and toured facility |
| Shobhana Frank | Licensing Program Analyst | Conducted the inspection visit |
| Marina Stanic | Licensing Program Manager | Named as Licensing Program Manager on report |
Report
October 21, 2025
Report
June 24, 2022
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