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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 10/18/2022
Date Signed: 11/15/2022 02:48:33 PM

Substantiated


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
12/28/2020 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20201228121131
FACILITY NAME:HARVEST RETIREMENTFACILITY NUMBER:
306005207
ADMINISTRATOR:GINGER POFACILITY TYPE:
740
ADDRESS:9011 KNOTT AVETELEPHONE:
(714) 821-4130
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:106CENSUS: 72DATE:
10/18/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Danielle Lucero, Care Coordinator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff not providing a safe environment for resident.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez made an unannounced visit to deliver findings on the allegation listed above. LPA Mendivil spoke Danielle Lucero, Care Coordinator and discussed the above allegation. Administrator Jeffery Po arrived at 2:05 PM.

It was alleged Resident 1 (R1) entered the room of Resident 2 (R2) and Resident 3 (R3) without permission in the middle of the night. Based on the interview conducted by LPA Marin with Chris Salvador, Director of Operation it was confirmed that R1 did enter the room of R2 and R3. R1 was given an overview of the house rules and given a warning. R2 was told to lock their door at night to stop anyone from entering.

Based on the preponderance of evidence through interviews the allegation that facility staff did not provide a safe environment for resident is found to be SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred. Deficiencies are being cited, an exit interview was conducted and a copy of this report was left at the facility. Appeals rights were provided as well. An amended 9099-D provided on 11/15/22.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20201228121131
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2022
Section Cited
CCR
87468.1(a)(2)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is requirement is not met as evidence by:
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Facility provided R1 with house rules and a warning, R1 no longer resides at facility, Corrected prior to visit.
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Based on interviews with residents and staff R2 and R3's room was accessed by R1 without their consent. This poses a potential safety risk to persons in care.
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2