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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613256
Report Date: 07/01/2022
Date Signed: 07/01/2022 03:41:12 PM

Document Has Been Signed on 07/01/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LITTLE HARBOR BOARD & CAREFACILITY NUMBER:
300613256
ADMINISTRATOR:PARKER, STACEY SHAWNFACILITY TYPE:
735
ADDRESS:551 S. HARBOR BLVD.TELEPHONE:
(714) 999-9990
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 4CENSUS: 1DATE:
07/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stacey ParkerTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management inspection to follow up on incident report received 6/27/2022. LPA Gutierrez met with Administrator (AD) Stacey Parker and discussed the purpose of the inspection. Incident Report dated 6/27/2022 states an unknown female stole the vehicle Client1 (C1) was sitting in when AD stepped away, leaving keys in the ignition.

Interview was conducted with AD who stated they were at the DMV to replace C1's lost identification card. AD reports parking as close as possible to the entrance of the DMV in a designated parking space and leaving the C1 in the vehicle with the air conditioning running due to hot weather. AD then went into building and was inside five to eight minutes before returning outside to find the vehicle the C1 had been sitting in was gone. Police were called. AD says a police report has yet to be issued but was able to provide LPA with a business card for a Detective of the Anaheim Police Department. C1 was returned safely to facility the following day on 6/23/2022. AD took C1 to urgent care Gateway Medical Center on the same day and was able to provide LPA with report.

LPA reviewed resident’s file and found a physician report for C1 dated 3/15/2022 that stated C1 is not able to leave facility unassisted. LPA determined that AD did not provide care and supervision; a deficiency was cited on this date. An exit interview was conducted and a report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2022 03:41 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 07/01/2022 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LITTLE HARBOR BOARD & CARE
FACILITY NUMBER: 300613256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.


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Administrator (AD) Stacey Parker stated they will create a plan of action for meeting the needs of the client which includes how to ensure care and supervison will be met and sumbit POC by POC date to LPA via email.
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The requirement was not met as evidence by; during the course of the investiagtion and interviews conducted LPA determined that the administrator left Client1 (C1) unassited in a vehicle that was left running with the keys in the ignition.
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
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