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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005207
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:10:18 PM


Document Has Been Signed on 10/13/2022 04:10 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
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: 72DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jeffrey PoTIME COMPLETED:
04:15 PM
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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 Administrator (AD) Jeffrey Po.

The purpose of today's visit was to follow up and gather additional details on the Unusual Incident Reports (LIC624) sent to the Orange County Adult and Senior Care Program Regional Office September 23, 2022.

On today's visit LPA Haley interviewed R1, R2, and AD Po regarding the reported incidents.

LPA Haley received copies of the Physicians Report, and Preplacement Appraisal information for R1 and R2.

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

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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