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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 11/05/2020
Date Signed: 11/05/2020 12:55:51 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
08/12/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200812115230
FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:AHAOMA S. ONYEBUCHIFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 860-4016
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 57DATE:
11/05/2020
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Paul BrownTIME COMPLETED:
01:16 PM
ALLEGATION(S):
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Facility does not have a working phone.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joseph Alejandre, Criss Trinidad and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to deliver findings on a complaint investigation. LPAs and LPM identified themselves and discussed the purpose of the visit and the elements of the allegation with Administrator Paul Brown. On 8/12/2020, a complaint was received by the Department, the allegation was, facility does not have a working phone. The investigation revealed the following; there was no telephone service from 8/8/2020 to 8/19/2020. Interviews with staff and residents verified the telephone system did not work during 8/8/2020 to 8/19/2020. Licensing Program Analyst (LPA) Joseph Alejandre verified the telephone system was not operational by calling the facility number on multiple occasions on 8/13/2020, 8/17/2020 and 8/18/2020 and the number was not available. Facility staff and residents verified that the facility posted notices in the common areas and informed residents that the telephone system was down after 8/10/2020. Facility staff reported that back up telephone numbers were listed on the notices so people could contact the facility until the telephone service was restored. (Continued on LIC 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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 3
Control Number 22-AS-20200812115230
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: 11/05/2020
NARRATIVE
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(Continued). Witnesses reported that responsible parties were not notified the telephone system was not operational. No evidence was provided to show responsible parties of residents were notified about the telephone system being non-operational. The facility did employ measures to attempt to minimize the impact of the telephone service being interrupted. Signs were posted showing temporary numbers to use to contact the facility. This information was posted throughout the facility. It was reported that the previous management company had not notified the new management company of the status of the phone service account which led to the discontinued telephone service. Evidence gathered showed the new management company is now the new account owner for the telephone service utility and financially responsible for the telephone service account. Even though the new Administrator and management company were not notified about the status of the utility it is their responsibility to ensure the facility meets the requirements of Title 22 and ensure the residents and responsible parties have access to the facility through telephone service. When a facility loses a utility such as telephone service, the facility must report such incidents to licensing. Licensing was made aware of the issue through a third party. No special incident report was received by Licensing concerning the interruption of telephone service. Licensing Program Analyst Joseph Alejandre spoke with facility Administrator concerning the telephone service being restored. Licensing reached out to the facility as part of the investigation and the facility fully cooperated with the investigation but the facility is still responsible for reporting such incidents in writing to the Department (CCL). Based on the evidence gathered, 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 with Paul Brown and a copy of this report along with citations and Appeal Rights (LIC 9058 01/16) was provided to Paul Brown.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20200812115230
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2020
Section Cited
CCR
87344
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87344 - Telephones; All facilities shall have telephone service on the premises. This requirement is not being met as evidenced by; Facility staff verified the facility did not have phone service from 8/8/2020 to 8/19/2020.
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Licensee states the facility will have continued uninterrupted phone service at the facility by maintaining the phone equipment and keeping an up to date account with the phone service provider. Licensee has corrected this deficiency. Proof of correction has been received and facility file updated.
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This poses an immediate health and safety risk to residents and staff at the facility.
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Type B
11/12/2020
Section Cited
CCR
87211(a)(1)(D)
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87211 - Reporting Requirements; A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified... Any incident which threatens the welfare, safety or health of any resident...
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Licensee states the facility will train staff on when to report incidents/events to management and CCL. Administrator will forward proof of training to CCL by POC due date.
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This requirement is not being met as evidenced by; the facility did not submit a special incident report to the Agency to report the event. This poses a potential health and safety risk to the residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3