306005207-3-5-2024-22-AS-MSTC-DG96ZY-20250430211550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 03/05/2024
Date Signed: 03/05/2024 05:42:13 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
03/01/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240301162515

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: 70	DATE:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Jeffery Po - Administrator		TIME COMPLETED:	05:55 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received March 1, 2024. LPA Haley was greeted by staff and explained the reason for the visit upon entry.
During the visit, LPA Haley conducted staff interviews and collected relevant documents.

Regarding the allegation: Staff did not seek medical attention for resident in a timely manner.

2 of 2 staff interviewed confirmed Resident 1 (R1) had a change in condition observed by staff and was not assessed or sent out for an evaluation after the change in condition. Staff interviews revealed sometime during the morning of February 22, 2024, Staff 3 (S3) observed Resident 1 (R1) weak and unable to stay balanced. R1 was given a wheelchair and S3 spoke to Staff 4 (S4) regarding the change in condition. However, R1 was never assessed and never sent out to be evaluated regarding the change in condition.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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-20240301162515

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: 03/05/2024

NARRATIVE

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Later in the day around noon, R1 received a visit from family who made some concerning observations including facial drooping and R1 being in a wheelchair. The family member requested R1 be sent to the hospital and that’s when the facility arranged for R1 to be sent to the hospital for a medical evaluation.

Staff 1 (S1) admitted R1 should have been evaluated and sent out based on the residents change in condition observed by S3.

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, Chapter 1.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240301162515

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: 03/05/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/12/2024 Section Cited CCR 87565(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical care... and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical... needs. This includes transportation which may be limited to the nearest available medical... facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.	1 2 3 4 5 6 7	Administrator Po will read and review regulations section 87465 on Incidental Medical and Dental Care. Upon completion Administrator Po will email LPA Haley a plan of action that outlines the steps that will be taken to prevent this from happening again. Administrator Po will cover Incidental Medical and Dental Care with all staff and send a signed acknowledgement (from all staff) the regulation section was covered and understood. POC will be emailed to LPA Haley by 5:00PM Tuesday, March 12, 2024.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by a resident having a change in condition observed by staff and the staff failing to get the resident medical attention in a timely manner. The resident was sent out to the hospital to be evaluated a few hours later. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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