306005678-9-27-2023-22-AS-SSAS-CWB2UE-20231004174210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:25:25 AM

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
08/24/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200824105352

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: 159	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Yaylene Mazariegos		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not respond to call light in a timely manner.
Staff did not treat resident with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings on the two allegations listed above. LPA met with Assistant Administrator Yaylene Mazariegos and explained the reason. The investigation into the allegation, staff did not respond to call light in a timely manner, revealed the following. It was reported that Resident 1 (R1) pulled the cord to activate the signal system requesting assistance and staff took 30 minutes to respond. Staff reported that R1 requested assistance sometime after 12:00 am on 8/23/20 but could not provide an exact time. Staff interviewed reported that once R1 pulled the cord they were assisted in around 10 minutes. R1 reported that they called for assistance around 11:00 pm on 8/22/20. R1 and staff reported conflicting information regarding the time assistance was requested. R1 reported that assistance did arrive, but they do know the exact time they arrived or how long it took to arrive. At the time of the complaint the call system did not track response time. Based on the information provided the allegation, staff did not respond to call light in a timely manner is 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.

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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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 5

Control Number 22-AS-20200824105352

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: 09/27/2023

NARRATIVE

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The investigation into the allegation, staff did not treat resident with respect, revealed the following. It was reported that staff did not treat Resident (R1) with respect on 8/22/20 & 8/23/20 when interacting with R1. LPA interviewed 5 staff members who interacted with R1 on 8/22/20 and 8/23/20. 5 out of the 5 staff members interviewed denied disrespecting R1 or any resident. R1 reported that they don’t believe they have been disrespected by facility staff. R1 reported that they did not recall any unusual interactions with staff on 8/22/20 or 8/23/20 that would be considered disrespectful. Based on the information provided the allegation, staff did not treat resident with respect is 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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/24/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200824105352

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: 159	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Yaylene Mazariegos		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the finding for the allegation listed above. LPA met with Assistant Administrator Yaylene Mazariegos and explained the reason. The investigation into the allegation, staff did not seek medical attention in a timely manner, revealed the following. It was reported that Resident 1 (R1) requested to go to the hospital due to foot pain, but staff ignored his request. R1 reported that they requested to go to the hospital, due to pain in their right foot, after staff answered their call for assistance. LPA interviewed Staff 1 (S1) who reported the resident did request assistance and reported pain, so they provided R1 with their PRN pain medication. It is unclear if the call for assistance was at 11:00 pm on 8/22/20 or 12:00 am on 8/23/20. S1 reported that they could not recall if R1 requested to go to the hospital. On 8/23/20 around 8:00 am. Staff 2 (S2) was informed by R1 they were in pain, so they called 911 and the paramedics came to the facility. S2 and R1 both reported that the paramedics informed R1 that the hospital they would take R1 to has a high volume of patients so the wait could be long because R1 is not suffering a life-threatening injury. R1 refused to go with the paramedics. R1 and staff verified this information.

Substantiated

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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20200824105352

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: 09/27/2023

NARRATIVE

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S2 called an ambulance service to take R1 to a local urgent care facility. R1 was not present when the ambulance arrived. R1 reported that they took a taxi to a hospital for treatment. S2 reported that they were unaware that R1 decided to transport themselves to the hospital. A review of medical records shows R1 was treated at Anaheim Regional Medical Center on 8/23/23 and suffered a Metatarsal Fracture on their right foot and released on 8/23/20. When residents request assistance in receiving medical care, the facility is responsible for assisting or arranging for medical care appropriate to the conditions and needs of the resident. R1’s first request for assistance in going to the hospital was not followed. On 8/23/23 around 8:00 am staff acted on R1’s second request and called 911 for R1. Regardless of a resident’s refusal for treatment facility staff are required to assist residents and call for assistance on their behalf. Based on evidence gathered through observation, interviews and medical records, 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 and a copy of appeal rights and the report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20200824105352

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: 09/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/28/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by.	1 2 3 4 5 6 7	Licensee agrees to train staff on CCR 87465, incidental medical and dental care. Licensee agrees to submit proof of training for all staff to LPA by 10/09/2023.
	8 9 10 11 12 13 14	R1 requested staff call 911 due to a foot pain but staff ignored the initial request. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5