306005678-1-25-2023-22-AS-SSAS-CNP4ZF-20230202183237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:51:12 PM

Unsubstantiated

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
05/27/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200527083004

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: 129	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Christine Chon - Executive Director		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is refusing to give resident medicated shampoo
Staff did not refill medication

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and initially met with Business Office Manager Roger Cortes and explained the purpose of the visit. Executive Director (ED) Christine Chon arrived later and assisted LPA with the visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA also requested and obtained copies of facility and resident records. During the course of the investigation, LPA Velazquez conducted interviews with residents and staff. LPAs Ruth Martinez and Patricia Velazquez also requested and obtained copies of facility and resident records. Regarding the allegation: Staff is refusing to give resident medicated shampoo, the investigation revealed the following: the records reviewed included Physician's Reports, Admission Agreements, Resident Identification and Emergency Information, Physician's Orders for

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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-20200527083004

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: 01/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medications, Resident (R) #1's Quick MAR (Medication Administration Record) for May 2020, June 2020 and January 2023 with Physician's Orders for Medications, R1's statement from Guardian Pharmacy dated January 2, 2023 with a balance due of $531.95 and due on January 20, 2023. Eight of nine individuals interviewed could not corroborate the allegation as they indicated medications were being administered as directed by the residents' physicians. Three of three individuals interviewed reported R1 will at times ask for medication sooner than what is ordered by the physician and staff reminds R1 that they are providing R1's medications in accordance with R1's physician's orders.

Regarding the allegation: Staff did not refill medication the investigation revealed the following: the records reviewed included Physician's Reports, Admission Agreements, Resident Identification and Emergency Information, Physician's Orders for Medications, Resident (R) #1's Quick MAR (Medication Administration Record) for May 2020, June 2020 and January 2023 with Physician's Orders for Medications, R1's statement from Guardian Pharmacy with a balance due of $531.95 and due on January 20, 2023. Eight of nine individuals interviewed could not corroborate the allegation. These individuals stated resident medication are always refilled in a timely manner to ensure a resident receives their medication as directed by their physicians. Guardian Pharmacy has put a hold on some of R1's medications because R1 has an outstanding balance of $531.95.

Based on the observations made, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff is refusing to give resident medicated shampoo and Staff did not refill medication are deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Christine Chon and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2