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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005678
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:14:47 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
08/31/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200831131936
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: 38DATE:
06/17/2021
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Khatera BahadoryTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff are not showering resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Joseph Alejandre made an unannounced visit to deliver the findings on the above allegation. LPA Alejandre identified himself and discussed the findings with Wellness Director Khatera Bahadory. In regards to the allegation; staff are not showering resident, the investigation revealed the following. Resident 1's (R1) admission agreement lists 2 showers a week will be provided for R1. Staff reported that R1 is currently receiving 3 showers a week. R1 verified he is currently receiving 3 showers a week. Reporting Party could not provide any dates or times when R1 missed showers. R1 could not recall dates or times when showers were not provided. It was reported that Home Health was providing R1 a shower once a week, which ended in September 2020, the facility was providing 2 showers a week at that time. When Home Health service ended the facility provided R1 3 showers a week. It remains unclear when the facility began providing R1 with 3 showers a week, R1 and the staff could not verify when it actually took place and the documentation is incomplete. What is clear is that staff and R1 report, R1 has continued to receive 3 showers a week and is currently receiving 3 showers a week, which is 1 more shower than agreed to in the admission agreement.
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: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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 2
Control Number 22-AS-20200831131936
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: 06/17/2021
NARRATIVE
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Therefore the allegation is deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with the Wellness Director and a copy of this report was provided
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2