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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005678
Report Date: 02/05/2024
Date Signed: 02/05/2024 04:32:28 PM


Document Has Been Signed on 02/05/2024 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
306005678
ADMINISTRATOR:CHRISTINE CHONFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 172DATE:
02/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Christine Chon, Executive DirectorTIME COMPLETED:
04:45 PM
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On today's date, Licensing Program Analysts (LPAs) Rosie Quiroz and Dwayne Mason conducted this case management in conjunction to the 10 day visit for Complaint Control #:22-AS-20240201111153

LPAs met with Executive Director (ED) Christine Chon and discussed purpose of today's case management.
On or about 2:14pm, while LPAs toured Resident 1's (R1s) bedroom area, LPAs observed cracked ceiling with leak above (R1s) bed area. (R1) indicated "I told the staff about the cracked ceiling, my heater not working and my loose door, but they haven't done anything about it."

Today's observations conducted by LPAs were verified with (ED) Chon. (ED) Chon agreed to relocate (R1) to another bedroom.

Facility was provided with a Technical Violation LIC 9102 TV. An exit interview was conducted with (ED) Christine Chon, and a copy of this report and LIC 811-Confidential names were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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