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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:50:12 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
02/06/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240206145710
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: DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Danielle LuceroTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff handled resident in a rough manner, resulting in resident sustaining a bruise
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation made February 6, 2024. LPA Haley was greeted by staff and explained the reason for the visit.
Regarding the allegation: Staff handled resident in a rough manner, resulting in resident sustaining a bruise

The investigation consisted of interviews and document review. Interviews with 4 of 5 individuals confirmed Resident 1 (R1) sustained bruising to the left arm. Document review and interview confirmation revealed that R1 complained to Staff 4 (S4) about pain to the arm after being showered by Staff 2 (S2). S4 reported the information to Staff 1 (S1). According to S1, it was reported that R1 was on the bed when S2 yanked or pulled R1’s arm because it was time to shower. According to S1, after gathering details on the incident, an in-service training was conducted and an Employee Warning Notice signed and dated by S2 and Staff 3 (S3) was issued to S2 for the employees actions.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
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 3
Control Number 22-AS-20240206145710
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: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Staff 2 was given a written warning and an in-service training was held for staff on agressive behavior. No further action is required.
A copy of the written notice provided to Staff 2 was provided and a copy of the and in-service training will be emailed to LPA Haley.
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This requirement is not being met as evidenced by Staff 2 handling Resident 1 roughly during showers on February 2, 2024 which poses a health, safety and personal rights risk to residents 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240206145710
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: 06/10/2024
NARRATIVE
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Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3