306005678-5-3-2023-22-AS-AORZ-CTPLEP-20230713084151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 05/03/2023
Date Signed: 05/03/2023 09:47:48 AM

Unfounded

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
11/17/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211117161118

FACILITY NAME:	HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE		FACILITY NUMBER:	306005678
ADMINISTRATOR:	PAUL BROWN		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(714) 459-3353
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	199	CENSUS: 148	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Christine Chon		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility refused to take resident back.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Executive Director Christine Chon and explained the reason for the visit. The investigation into the allegation, facility refused to take resident back, revealed the following. It was alleged that Resident 1 (R1) was not allowed back to the facility when they were discharged from the hospital on 11/14/21. R1 went to the hospital on 11/13/21 (see Harbor Heights complaint # 22-AS-20211115104247 dated 11/15/21) and returned the next day, 11/14/21. All witnesses interviewed corroborated this information. A review of hospital discharge documents shows R1 was discharged on 11/14/21. A review of R1’s medication administration record shows R1 was administered their medication at the facility on 11/14/21. None of the evidence gathered through interviews and a review of records supports the allegation, therefore the allegation, facility refused to take resident back is deemed, unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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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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
11/17/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211117161118

FACILITY NAME:	HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE		FACILITY NUMBER:	306005678
ADMINISTRATOR:	PAUL BROWN		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(714) 459-3353
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	199	CENSUS: 148	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Christine Chon		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility failed to follow medication orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Executive Director Christine Chon and explained the reason for the visit. Regarding the allegation, facility staff failed to follow medication orders, the investigation revealed the following. It was alleged the facility let Resident 1 (R1) draw up too much insulin for themselves on 11/13/21. This led staff to having R1 transported to the hospital. A review of records show that the facility manages R1’s medication except for; R1 tests their own glucose levels and administers their own insulin injections. R1 is prescribed 3 units of insulin (3mL). All witnesses interviewed reported conflicting information regarding R1 administering insulin on the morning of 11/13/21, either 5 units or 3 units of insulin were draw up. It is unclear if any insulin was administered because of conflicting witness reports. It was reported that R1 could administer their own insulin upon discharge from the hospital as prescribed by their primary care physician. All witnesses interviewed corroborate this information. A review of R1’s medication administration record shows R1’s medications for November 2021 were administered as prescribed while at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20211117161118

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: 05/03/2023

NARRATIVE

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There is no evidence to support the allegation. Based on the evidence gathered through a review of records and interviews the allegation, facility staff failed to follow medication orders is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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