306005678-6-15-2020-22-AS-SSAS-BQXUPU-20200626154606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 06/15/2020
Date Signed: 06/15/2020 02:03:25 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
04/24/2020 and conducted by Evaluator Michael Barrett

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200424140507

FACILITY NAME:	HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE		FACILITY NUMBER:	306005678
ADMINISTRATOR:	AHAOMA S. ONYEBUCHI		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(714) 860-4016
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	199	CENSUS: 60	DATE:	06/15/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Business Office Manager (BOM) Scarlet Augafa		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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-Staff is not assisting with the administration of medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Mike Barrett, contacted the facility via tele-visit to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA Barrett spoke with Business Office Manager (BOM) Scarlett Augafa, identified himself and stated the purpose for the call, which was to deliver the findings of the investigation. On April 24, 2020, a complaint was received by the Orange County Adult and Senior Care Program regarding the, above mentioned, allegation and was assigned to LPA Barrett. The investigation consisted of interviews and records review.

It was alleged that the staff are not assisting the resident with the administration of medications.
LPA Barrett conducted interviews with the Executive Director, five (5) staff members (staff #1 (S1), staff #2 (S2), Staff #3 (S3), staff #4 (S4) and staff #5 (S5)), two witnesses and obtained and reviewed records from the facility pertaining to Resident #1 (R1).

Continued on page 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200424140507

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
	VISIT DATE: 06/15/2020

NARRATIVE

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Continued from page 1.

Through interviews and file review, LPA Barrett observed that R1 was prescribed Norco 5-325mg tablet every 8 hours, PRN by R1’s primary care physician for pain management. Interviews with S1, S2, S3, S4, and S5 as well as review of R1’s Medical Administration Record (MAR) shows that the facility was giving R1’s medication as prescribed.

This agency has investigated the complaint alleging that the staff are not assisting the resident with administration of medications. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were observed and no citations were issued during this visit.

An exit interview was conducted with Business Office Manager, Scarlet Augafa via telephone and a copy of this report along with LIC 811 (confidential names list) was provided to Business Office Manager Augafa via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

LIC9099 (FAS) - (06/04)

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