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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005207
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:54:36 PM


Document Has Been Signed on 09/11/2024 04:54 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
ORANGE COUNTY RO, 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: 81DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rose EnriquezTIME COMPLETED:
05:05 PM
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Licensing Program Analysts (LPAs) Jerome Haley, Jessica Cho, and Samer Haddadin arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs were greeted and granted entry by Assistant Administrator Rose Enriquez, LVN. LPAs also met with Assistant Administrator Danielle Lucero, and Business Office Manager Edith Marinero.

The facility is licensed for 106 and maintains a hospice waiver of 30 residents. As of today, the resident census is 81 of which 2 are receiving hospice care. LPA Haley conducted a tour of the physical plant and observed the following:

This is a two-story commercial building comprised of an Assisted Living (AL) Memory Care Unit. LPA Haley inspected all common areas. LPA inspected 8 resident bedrooms which had all the required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the non-skid mats were in place. The hot water temperature measured within the range of 105.9 -119.4 degrees Fahrenheit. LPAs inspected the kitchen and the dining area. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water.

Multiple fire extinguishers were observed on the walls, fully charged, and serviced in February of 2024. The smoke detectors were last tested on July 4, 2024 by Fire Safety Service INC, which was verified on the inspection report. LPA toured the outside grounds. There were sufficient seating and shading for the residents, and the walkways were clear of hazards. A locked storage shed used to store cleaning chemicals was observed outside in the parking lot area. All exit gates were self-closing and self-latching.

Continued on LIC809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HARVEST RETIREMENT
FACILITY NUMBER: 306005207
VISIT DATE: 09/11/2024
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LPAs observed sufficient PPE and emergency disaster supplies including food/water. Emergency evacuation drills are conducted quarterly, and facility is maintaining a log documenting the drills. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. Facility maintains a current liability insurance.

LPAs Cho and Haddadin reviewed eight residents’ files. No discrepancies noted. LPAs reviewed two staff files. No discrepancies noted. Interviews were conducted with seven out of eight residents as one resident refused. The two staff interviews were not conducted as they had ended their shift. The medications and the Medication Administration Records (MARs) were reviewed for 4 residents. No discrepancies noted.

Based on LPAs observations, no deficiencies will be cited as a result of today's visit. A Technical Advisory (TVs) is being issued.

An exit interview was conducted with Business Office Manager Edith Marinero, and Assistant Administrator Danielle Lucero, and Assistant Administrator Rose Enriquez. A copy of this report was provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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