<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005207
Report Date: 08/23/2022
Date Signed: 08/23/2022 11:15:29 AM


Document Has Been Signed on 08/23/2022 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 74DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Danielle LuceroTIME COMPLETED:
11:22 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management at Harvest Retirement. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley met with Assistant Administrator Danielle Lucero.

The purpose of today's visit was to conduct a Case Management visit to discuss Unusual Incident Reports (LIC 624) that were sent to the Orange County Adult and Senior Care Regional Office August 8th and August 17, 2022.

On today's visit LPA Haley conducted a brief interview regarding the separate incidents involving Resident 1 (R1) on August 2, and Resident 2 (R2) on August 16, 2022. LPA Haley received copies of R1's most recent Physicians report, and reviewed the admission agreement. LPA Haley received R2's emergency contact information, first and most recent Physicians Report.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 1