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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005207
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:31:01 PM


Document Has Been Signed on 12/27/2022 02:31 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:HARVEST RETIREMENTFACILITY NUMBER:
306005207
ADMINISTRATOR:GINGER POFACILITY TYPE:
740
ADDRESS:9011 KNOTT AVETELEPHONE:
(714) 821-4130
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:106CENSUS: 73DATE:
12/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Betty Robinson & Raul PereiraparraTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit for the purpose of conducting a Case Management visit regarding the Unusual Incident Report (LIC 624) sent to the regional office December 6, 2022. LPA spoke with Staff 1 (S1) and Staff 2 (S2) regarding the incident.

Regarding the incident report dated 11.28.22, LPA Haley received a copy of Resident 1's (R1) physicians report, and signed move out form. R1 made the decision to move out of the facility December 20, 2022.

No deficiencies are being cited as a result of today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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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