Other·January 10, 2024

PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA060000033 (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A000 The following reflects the findings of the California Department of Public Health during a staffing audit visit for 24 randomly selected days from 11/29/2020 to 02/28/2021. Representing the Department: P.V., Associate Governmental Program Analyst. Welfare and Institutions (W&I) Code section 14126.022 sets forth the Department's authority to conduct audits of direct caregiver nursing services provided to residents of skilled nursing facilities, and to establish procedures for conducting such audits through All Facility Letters (AFLs). <http://leginfo.legislature.ca.gov/faces/codes_di splaySection.xhtml? sectionNum=14126.022.&lawCode=WIC> AFL 21-11, setting forth the audit process and guidelines for facilities is available through the following link: <https://www.cdph.ca.gov/Programs/CHCQ/LC P/Pages/AFL-21-11.aspx> Health and Safety Code (HSC) 1337-1338.5, sets forth the requirements for Certified Nurse Assistants is available through the following link: <https://leginfo.legislature.ca.gov/faces/codes_ displayText.xhtml? division=2.&chapter=2 .&lawCode=HSC&article=9> W&I section 14126.022 requires the Department to assess an administrative penalty to a SNF if the Department determines that the SNF fails to meet the DHPPD requirements pursuant to HSC sections 1276.5 Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 YM8H11 TITLE (X6) DATE If continuation sheet 1 of 5 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA060000033 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or 1276.65. The Department shall assess an administrative penalty to any facility that fails to meet the applicable standard for staffing requirements on any given day. The applicable standard is 3.5 DHPPD and 2.4 DHPPD (CNA), unless an approved Workforce Shortage, Patient Needs, or COVID-19 Waiver is granted. The statute was not met as evidenced by the following findings: Final Audit Result: Total Distinct Non-Compliant Day(s) = 23 Date 3.2 3.5 2.4 11/29/2020 *.00* *.00* .00 12/01/2020 *.00* .00 .00 12/03/2020 *.00* .00 .00 12/05/2020 3.31 2.15 12/09/2020 *.00* .00 .00 12/12/2020 *.00* .00 .00 12/13/2020 *.00* .00 .00 12/14/2020 *.00* .00 .00 12/15/2020 *.00* .00 .00 12/25/2020 *.00* .00 .00 12/28/2020 *.00* .00 .00 01/05/2021 *.00* .00 .00 01/06/2021 *.00* .00 .00 01/08/2021 *.00* .00 .00 01/15/2021 *.00* .00 .00 01/19/2021 *.00* .00 .00 01/21/2021 *.00* .00 .00 01/27/2021 *.00* .00 .00 02/03/2021 *.00* .00 .00 02/05/2021 *.00* .00 .00 02/07/2021 *.00* .00 .00 02/18/2021 *.00* .00 .00 02/19/2021 *.00* .00 .00 02/24/2021 *.00* .00 .00 *x.xx* = non-compliant date Licensing and Certification Division STATE FORM 6899 YM8H11 If continuation sheet 2 of 5 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA060000033 (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A150 HSC 1276.5(a) SAS - 3.2 Standard ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A150 (a) The department shall adopt regulations setting forth the minimum number of equivalent nursing hours per patient required in skilled nursing and intermediate care facilities, subject to the specific requirements of Section 14110.7 of the Welfare and Institutions Code. However, notwithstanding Section 14110.7 or any other law, commencing January 1, 2000, the minimum number of actual nursing hours per patient required in a skilled nursing facility shall be 3.2 hours, except as provided in Section 1276.9. This Statute is not met as evidenced by: Facility failed to meet 3.2 Direct Care Service Hours per Patient Day (DHPPD) pursuant to HSC section 1276.5(a) for 22 out of 24 days. The statute was not met as evidenced by the following findings: The total number of actual direct care nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet DHPPD Staffing Standard(s). Facility failed to maintain current, complete and accurate personnel and payroll records for all employees in accordance with CCR Title 22, section 72533. Time spent providing direct care could not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Licensing and Certification Division STATE FORM 6899 YM8H11 If continuation sheet 3 of 5 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA060000033 (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A200 HSC 1276.65(c)(1)(B) SAS - 3.5 Standard ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A200 (B) Effective July 1, 2018, skilled nursing facilities, except those skilled nursing facilities that are a distinct part of a general acute care facility or a state-owned hospital or developmental center, shall have a minimum number of direct care services hours of 3.5 per patient day, except as set forth in Section 1276.9. This Statute is not met as evidenced by: Facility failed to meet 3.5 Direct Care Service Hours Per Patient Day (DHPPD), Pursuant to HSC 1276.65(c)(1)(B) for 1 of 24 days. The statute was not met as evidenced by the following findings: The total number of actual direct care nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet DHPPD Staffing Standard(s). Facility failed to maintain current, complete and accurate personnel and payroll records for all Licensing and Certification Division STATE FORM 6899 YM8H11 If continuation sheet 4 of 5 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA060000033 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE employees in accordance with CCR Title 22, section 72533. Time spent providing direct care could not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Licensing and Certification Division STATE FORM 6899 YM8H11 If continuation sheet 5 of 5