306005207-7-27-2022-22-AS-AORZ-CH6LKK-20220810084940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:26:42 AM

Unfounded

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
07/12/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210712114808

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: 74	DATE:	07/27/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Danielle Lucero		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Residents are not properly fed while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit for the purpose of delivering findings on the above allegation. LPA was greeted and granted entry into the facility by Business Office Manager Raul Pereira and explained the reason for the visit. Assistant Administrator Danielle Lucero was present as well.
During the course of the investigation, LPA toured the kitchen, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and individual service plan. Regarding the allegation that residents are not properly fed while in care, the investigation revealed the following: Per physician report dated 09/03/2021, Resident 1 (R1) is diabetic. However there is not an order for a restricted diet and R1 confirms there is no current or prior order. R1's Individual Service Plan indicates a plan for the resident to be cognizant of eating habits and weight gain but has no parameters for specific food intake. R1 indicates the knowledge of proper diet but acknowledges not following the proper diet. Facility indicates the menu offers up food for the general population while keeping foods in mind for diabetic residents. Snacks offered between meals have diabetic options including sandwiches and no sugar choices. CONT ON LIC 9099C DATED 07/27/2022.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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-20210712114808

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: 07/27/2022

NARRATIVE

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LPA observed the menu posted with varied daily choices and R1 indicates there are choices that can be made off the menu. R1 states being monitored daily by a home health nurse for blood pressure and blood sugars. R1 is currently on injected insulin. Therefore, the allegations are deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC9099 (FAS) - (06/04)

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