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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005678
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:11:45 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: 50DATE:
11/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Paul BrownTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency received an incident report concerning a resident who had fallen and injured themself. The resident (R1) was taken to the ER and treated and returned the same day. Staff reported that R1 is checked at least once an hour. LPA interviewed R1 through a translator, and R1 stated she was doing fine and the staff have been very helpful. The facility staff called 911 when it was discovered that R1 had an accident. R1 was transported to the ER and treated and returned later that day. Facility has increased checks on R1 and R1 is to follow up with their primary care physician (PCP). No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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