306005207-10-5-2021-22-AS-AORZ-C7SVBX-20211014161815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 10/05/2021
Date Signed: 10/05/2021 12:52:34 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
09/29/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210929110259

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: 75	DATE:	10/05/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Jeffrey Po		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility has pests.
Resident is not accorded privacy.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit for the purpose of initiating a complaint visit. LPA was greeted and granted entry into the facility by Community Liasion Betty Robinson and explained the reason for the visit. Administrator Jeffrey Po arrived during the visit.

During the course of the investigation, LPA toured the facility, interviewed residents and staff as well as reviewed and obtained pertinent documentation such as facility admission agreement and extermination records. Regarding the allegations that facility has pests and resident is not accorded privacy, the investigation revealed the following: During the tour of resident rooms, LPA observed there are two call buttons in Resident 1's (R1) room. There is a call button in the bedroom area as well as one in the restroom. Five out of five residents who use the call button state the staff respond promptly when call button is pushed. LPA did not observe any ants during the tour and facility states utilizing Western Extermination for pest control. Facility provided documents indicating that Western Extermination treated nine rooms for ants on October 4, 2021 and seven rooms on September 9, 2021. CONTINUED ON LIC 9099C DATED 10/05/2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

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-20210929110259

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: 10/05/2021

NARRATIVE

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Four out of five residents interviewed deny seeing any ants in their rooms. LPA interviewed the two facility housekeepers regarding job duties and protocols. Both housekeepers deny moving belongings into drawers and state counter top belongings are moved to the side for dusting. Once dusting is complete, the items are moved back into their prior spot. When residents request their items not be touched, the housekeepers state they skip that particular dusting. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are 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 violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC9099 (FAS) - (06/04)

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