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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005678
Report Date: 08/11/2021
Date Signed: 08/11/2021 07:25:31 PM

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:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:PAUL BROWNFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 47DATE:
08/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:39 PM
MET WITH:Khatera BahadoryTIME COMPLETED:
07:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced subsequent visit. LPA was at the facility to conduct 10-day visit and to deliver findings of a previous complaint. LPA spoke with residents who reported the call system was not working. LPA pulled the call system cord at 5:50 pm in room 109, the unit blinked green, 15 minutes later no one had answered the call for assistance. LPA informed Khatera Bahadory and it was verified that the call system was not working for room 103 and 109. Once the cords were pulled no notification was sent to the computer at the front desk. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Khatera Bahadory and a copy of this report along with citation and Appeal Rights (LIC 9058 01/16) was provided to Khatera Bahadory.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 306005678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited

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Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall operate from each resident's living unit. This requirement is not met as evidenced by: based
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observation of the LPA the pull cord system for rooms 103 and 109 were not operational. Khatera Bahadory verifed they were not operating. This poses an immediate risk to the health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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