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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005678
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:44:45 PM


Document Has Been Signed on 06/08/2022 04:44 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:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:PATRICIA RAGERFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 77DATE:
06/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Patty RagerTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA was granted entry by staff. LPA met with Administrator Patty Rager. LPA explained the reason for the visit. The Agency (CCL) received two reports from the facility concerning Resident 1 (R1) falling and then days later passing away at the hospital. LPA interviewed the Administrator and reviewed R1's file. R1 suffered an unwitnessed fall at the facility and staff immediately called 911. R1 was transported to the hospital. R1 passed away days later. R1 resided in Assisted Living and did not have a care companion. Based on the information provided, through interviews, incident reports and record review show the facility took immediate action after R1 fell and called 911. Paramedics responded and transported R1 to the hospital for treatment. No deficiencies observed during the visit. LPA consulted with the Administrator concerning Covid-19 mitigation procedures and visiting guidelines. 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: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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