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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 10/18/2022
Date Signed: 10/18/2022 02:15:54 PM

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
12/30/2020 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201230092631
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:
10/18/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Danielle Lucero, Care Coordinator TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez made an unannounced visit to deliver findings on the allegation listed above. LPA Mendivil spoke Danielle Lucero, Care Coordinator and discussed the above allegation. Administrator Jeffery Po arrived at 2:05 PM.

It was alleged that Resident 1 (R1) R1 had items stolen from their room in the amount of $219. It was reported by Chris Salvador, Director of Operations that R1 had called Buena Park PD, but did not file a police report in regard to their stolen items. Based on interview conduct by LPA Marin, R1 denied calling Buena Park PD. During the interview R1 was not able to provide a clear list of items allegedly stolen. Interviews with 2 other residents revealed they have not experienced theft at the facility. In addition interview with staff Danielle Lucero, Care Coordinator she is not aware of any theft at the facility.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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-20201230092631
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: 10/18/2022
NARRATIVE
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Based on the preponderance of evidence through interviews the allegation Staff did not safeguard resident's personal belongings is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted and a copy of this report was left with a facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2