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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:19:33 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
05/10/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210510124518
FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:PAUL BROWNFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 173DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Christine ChonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident's property is not being protected
Staff are not providing a comfortable environment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation for the allegations listed above. LPA met with Executive Director Christine Chon and explained the reason for the visit.

The investigation revealed the following. It was alleged that the facility did not provide a comfortable environment for Resident 1 (R1). R1 reported that his roommate Resident 2 (R2) is disturbing the peace and making it so R1 cannot sleep at night. Staff reported that they have acknowledged R1’s reports and have asked R2 about it but R2 denies the reports. Staff interviewed have not witnessed any disrupting behavior by any residents. LPA interviewed R2 who denied the reports. R1 and R2 both acknowledged that in their admission agreements they agreed to have a shared room. Staff reported that with the remodeling of the rooms, residents had to be relocated and everyone was notified 60 days prior to moving. All residents interviewed verified this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 7
Control Number 22-AS-20210510124518
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: 12/14/2023
NARRATIVE
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R1 and R2 reported the room is fine and has enough room for both residents and the temperature is fine. Based on the evidence gathered, the allegation 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.

Regarding the allegation, resident’s property is not being protected, the investigation revealed the following. It was reported that Resident 1’s (R1) clothing and shoes were lost during their move to a new room. A review of records shows that there is no inventory list for R1’s property. R1 could not verify the exact items that were missing. The Administrator reported that when R1 moved to a new room, R1 was present as staff put R1’s belongings in boxes. The Administrator reported that R1 supervised the packing of their items and when everything was packed it was all moved at the same time to their new room and unpacked as R1 watched. 3 out of 3 staff interviewed reported that R1 was present while everything was moved. R1 verified that they were present during each step of the move. It was reported that the facility threw out R1’s refrigerator. The Administrator reported that R1’s personal refrigerator was inoperable, was leaking and only blew warm air. R1 verified this report. The Administrator reported that R1 agreed to have the refrigerator thrown out because it didn’t work. R1 verified this report. R1 verified that none of their personal items were given to the facility to safeguard.

Based on the evidence gathered the allegation 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 with the Administrator, and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
05/10/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210510124518

FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:PAUL BROWNFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 173DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Christine ChonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident's care needs are not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation for the allegation listed above. LPA met with Executive Director Christine Chon and explained the reason for the visit.

The investigation into the allegation, resident’s care needs are not being met, revealed the following. It was alleged that Resident 1’s (R1) wheelchair seat is 18 inches wide, and it should be 24 inches wide, and the facility was not assisting R1 in getting a new wheelchair. The Administrator reported that R1 is not eligible to receive a new wheelchair through Medicare or CalOptima at this time because it hasn’t been more than 5 years since they were last provided one. R1 verified this information. R1 was provided a wheelchair free of charge on or around 8/11/20 by the facility. Facility staff and R1 verified this information. A review of records shows R1 has a recent prescription for a wheelchair. The Administrator reported that R1’s prescription for a wheelchair was not honored by CalOptima and that he was informed that R1 would have to pay for a wheelchair out of pocket.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 7
Control Number 22-AS-20210510124518
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: 12/14/2023
NARRATIVE
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The Administrator reported they contacted 2 medical supply companies, and both informed the Administrator that insurance would not cover the expense and the cost would be out of pocket for R1. R1 verified this information. Medicare only covers the cost of a wheelchair once every 5 years.
R1 reported they received their original wheelchair sometime in 2019. This information could not be verified but based on the information gathered from R1 and facility staff, R1 most likely received their original wheelchair sometime in the last 5 years. The facility assisted R1 in attempting to get a new wheelchair. The facility previously provided R1 with a wheelchair free of cost on or around 8/11/20. The Administrator reported that the facility offered R1 another new manual wheelchair but R1 declined. R1 verified this report. R1 reported that they would like a new wheelchair. The facility is not required to provide R1 a wheelchair.

Based on the information provided the allegation, resident’s care needs are not being met, is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
05/10/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210510124518

FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:PAUL BROWNFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 173DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Christine ChonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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2
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Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation for the allegation listed above. LPA met with Executive Director Christine Chon and explained the reason for the visit.

The investigation into the allegation revealed the following. It was alleged that the Med-Techs at the facility tried to administer Seroquel (Quetiapine Fumarate 400 MG Tablet) to R1 at 7:00pm which is not the correct time. R1 reported that they should receive the medication at a later time (8:00pm) with another medication. 3 out of 3 staff interviewed reported that the Quetiapine Fumarate 400 MG Tablet is supposed to be administered at 7:00pm. A review of R1’s medication record for April 2021 and May 2021 shows that Quetiapine Fumarate 400 MG Tablet is supposed to be administered at 7:00pm based on R1’s physician’s orders. It was alleged that R1’s eye drops Azelastine 0.05% OPHTH were not administered to R1 because the facility staff did not refill the prescription timely.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20210510124518
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: 12/14/2023
NARRATIVE
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A review of records shows that on 5/10/2021, 5/11/2021, 5/12/2021 and 5/31/2021 R1 did not receive Azelastine 0.05% OPHTH because the facility was waiting for a delivery for the medication from the pharmacy. It is the responsibility of the facility to ensure residents do not run out of medication. The facility could not provide any verifications that the medication was ordered prior to running out.

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 and a copy of this report along with citation and Appeal Rights (LIC 9058 03/22) was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20210510124518
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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87464(f)(4)
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Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Licensee agrees to retrain med-tech staff regarding medication administration and CCR 87464(f)(4). Licensee to forward proof to LPA by poc due date.
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This requirement is not being met as evidenced by R1 was not administered Azelastine 0.05% OPHTH on 5/10/2021, 5/11/2021, 5/12/2021 and 5/31/2021 as prescribed by their physician. This poses an immediate health and safety risk to the resident.
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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7