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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005207
Report Date: 06/24/2022
Date Signed: 06/24/2022 03:06:56 PM


Document Has Been Signed on 06/24/2022 03:06 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: 75DATE:
06/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jeffrey Po TIME COMPLETED:
03:15 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 conduct a Case Management visit to discuss an Unusual Incident Report (LIC624) that was sent to the Orange County Adult and Senior Care Program Regional Office June 8, 2022.

On today's visit LPA Haley conducted an interview with AD Po regarding the incident involving Resident 1 (R1) and what has happened since the reported incident. LPA Haley reviewed the Admission agreement and received copies of a few pages of the agreement, as well as copies of the Physicians report, and LIC 601.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted with Administrator Po 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: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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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