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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:34:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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 RETIREMENTFACILITY NUMBER:
306005207
ADMINISTRATOR:GINGER POFACILITY TYPE:
740
ADDRESS:9011 KNOTT AVETELEPHONE:
(714) 821-4130
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:106CENSUS: 75DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rose Enriquez
Danielle Lucero		TIME COMPLETED:
02:45 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 an unannounced visit to the facility regarding additional information on the complaint allegation listed above. LPA explained the reason for the visit upon entry.
On October 22, 2024, the department received subpoenaed medical records from West Anaheim Medical Center (WAMC) regarding Resident 1 (R1). A review of the medical records reveal R1 was diagnosed with a stroke.
An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).
The facility was cited per Title 22, Division 6 of the California Code of Regulations. An amended deficiency is being cited on the attached LIC9099D. An immediate Civil Penalty is being assessed today in the amount of five hundred dollars ($500).
An exit interview was conducted, and a copy of this report, a copy of Civil Penalty Assessment Form and appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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-20240301162515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2025
Section Cited
CCR
87465(a)(2)
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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. This requirement is not being met as evidenced by:
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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.
POC was completed. No further action necessary.
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Based on interviews and record review, R1 had a change in condition observed by staff. Staff failed to get the resident medical attention in a timely manner causing R1 a serious injury. The resident was sent to the hospital to be evaluated a few hours later. This posed an immediate health and safety 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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2