306005678-9-8-2021-22-AS-LADS-C7JRAK-20211006125114

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 09/08/2021
Date Signed: 09/08/2021 04:33:37 PM

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
09/07/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210907112839

FACILITY NAME:	HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE		FACILITY NUMBER:	306005678
ADMINISTRATOR:	PAUL BROWN		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(714) 459-3353
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	199	CENSUS: 43	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Khatera Bahadory		TIME COMPLETED:	04:46 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights: Local Ombudsman information not available to residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the initial 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by Health and Wellness Director Khatera Bahadory. LPA explained the reason for the visit. LPA observed there was no Ombudsman poster showing the address and telephone number of the Ombudsman in the lobby of the facility. LPA verified with the Health and Wellness Director that the lobby was the only place the Ombudsman poster would be displayed. LPA toured the facility with the Health and Wellness Director, LPA did not observe any Ombudsman posters, posted in the facility. Health and Wellness Director reported that the poster had fallen off of the wall and had not been put back up. The Ombudsman poster was put up on the lobby wall during the LPA's visit. Based on the evidence gathered, through observation and interviews the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citations and Appeal Rights (LIC 9058 01/16) was provided to Khatera Bahadory

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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-20210907112839

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: HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE	FACILITY NUMBER: 306005678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/09/2021 Section Cited HSC 1569.269(a)(12)	1 2 3 4 5 6 7	To contact the ... ombudsman ... The licensee shall post the telephone numbers and addresses for the local offices ... and ombudsman program, in accordance with Section 9718 of the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents.	1 2 3 4 5 6 7	Licensee states the Ombudsman poster with the telephone number and address of the local Ombudsman will be posted in the lobby at all times. Licensee to provide proof of correction to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement is not being as evidenced by based on observation LPA did not observe the Ombudsman poster with telephone number and address posted in the facility. Health and Wellness director verified the Ombudsman poster was not posted in the facility. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2