306005207-4-21-2021-22-AS-SSAS-C3BQJT-20210524121315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 04/21/2021
Date Signed: 04/21/2021 01:31:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/27/2021 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210127152541

FACILITY NAME:	HARVEST RETIREMENT		FACILITY NUMBER:	306005207
ADMINISTRATOR:	GINGER PO		FACILITY TYPE:	740
ADDRESS:	9011 KNOTT AVE		TELEPHONE:	(714) 821-4130
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	106	CENSUS: 72	DATE:	04/21/2021
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Chris Salvador		TIME COMPLETED:	01:32 PM

ALLEGATION(S):

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Resident's property is not safeguarded by staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jim August contacted the facility via video telephone to conclude a complaint investigation via telephone due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call. The initial 10-day visit was completed on January 28, 2021.
The investigation into the allegation that the residents property is not safeguarded by staff revealed the following:

On January 28, 2021 LPA August interviewed Director of Operations Chris Salvador.
Salvador stated that resident 1 (R1) has claimed that his personal belongings have been stolen on multiple occasions. Staff attempted to locate what the resident claimed was missing however the resident would allege new items every so often. In addition, R1 would call 911 to report missing items, however with each phone call the resident claimed something new was missing.

On April 19, 2021 LPA August interviewed the roommate of R1, resident 2 (R2). Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210127152541

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARVEST RETIREMENT	FACILITY NUMBER: 306005207
	VISIT DATE: 04/21/2021

NARRATIVE

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R2 stated that he has never had any belongings stolen from the room. In addition, R2 has never heard R1 claim that he was missing anything or overheard any conversations R1 had explaining something was stolen. During the interview, LPA August observed R2’s wallet and cash laying on a stand next to him. LPA asked R2 if he normally leaves cash out in plain sight and R2 stated that he does, and it has never gone missing.

On April 19, 2021 LPA August attempted to interview R1. R1 explained that he had nearly $1,500 worth of personal property including earphone and exercise equipment as well as $1,000 in cash stolen. R1 could not specifically identify what else was missing and when the items were taken. R1 was unable to effectively communicate with LPA August.

On April 21, 2021 LPA August interviewed a witness (W1) who was very close to R1. W1 explained that he was unaware of anything being taken from R1 and that R1 is treated very well at the facility.

LPA August obtained R1’s LIC602 (Physicians Report) indicting that R1 was diagnosed with Dementia and needed assistance managing cash resources. In addition, LPA August obtained R1’s LIC621 (Resident Personal Property and Valuables) inventory sheet which was obtained upon R1’s admission to the facility. The items that R1 claimed to be missing were not listed on the LIC621.

As such, there is insufficient evidence to corroborate whether the above allegation has occurred. With the information obtained through the means described above, we have found the above allegation unsubstantiated. Although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

LIC9099 (FAS) - (06/04)

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