306006452-1-2-2026-22-AS-SHAN-DPXS2F-20260102122928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006452
Report Date: 01/02/2026
Date Signed: 01/02/2026 12:30:00 PM

Document Has Been Signed on 01/02/2026 12:30 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306006452
ADMINISTRATOR/ DIRECTOR:	DUSUN LEE		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(714) 459-3353
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 199		CENSUS: 194	DATE:	01/02/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Sammy Lee		TIME VISIT/ INSPECTION COMPLETED:	12:03 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. . Upon arrival, LPA Haddadin was greeted and granted entry by Case Manager, April Pena, in which the purpose of the visit was explained. On September 29, 2025, the Department received an incident report regarding the death of Resident (R1) following an unwitnessed fall that occurred on September 26, 2025. The investigation determined as follows: R1 was admitted to the facility on January 15, 2024, to the facility Assisted Living and later transferred to the facility’s Memory Care Unit on June 06, 2025, due to increased care needs. Prior to admission, a Physician’s Report dated December 14, 2023, and a Preplacement Appraisal dated January 15, 2024, documented that R1 was ambulatory, able to communicate needs, and able to ambulate using a cane and walker. While in care, R1 experienced multiple falls over time. Per facility documentation, the first reported fall occurred on April 30, 2025, while R1 was still in assisted living. Per incident report, R1 sustained an unwitnessed fall inside their room, was able to get up without assistance, and later complained of wrist pain. R1 initially did not report the fall right away to staff. R1 was transported to the hospital following reports of pain, where they were diagnosed with a wrist fracture. After R1 transitioned to the facility Memory Care on June 06, 2025, additional falls were documented. Facility records reflected a second fall occurred on September 08, 2025; a third fall on September 16, 2025; and a fourth fall on September 26, 2025. During an interview, Staff (S1) stated that, on September 08, 2025, R1 attempted to access the dining room while doors were locked for cleaning.{*CONTINUE 809C*}

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 306006452
	VISIT DATE: 01/02/2026

NARRATIVE

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S1 reported R1 was pulling on the doors while using a walker, lost balance, and fell. Hospital discharge paperwork dated September 08, 2025, documented a facial fracture involving the right maxillary sinus as a result of the fall. Regarding the September 16, 2025, fall, staff reported witnessing R1 fall in the hallway after turning into another resident, resulting in R1 losing balance and falling. R1 was transported to the hospital due to left shoulder pain, and a proximal humerus fracture was identified. On September 26, 2025, R1 experienced an unwitnessed fall in their room. Per incident report, R1 was found on the floor next to the bed. Facility staff contacted 911 and notified R1’s family. R1 reported the fall occurred while attempting to move from the bed to a table, and that the walker was located near the bed. R1 was transported to the hospital and did not return to the facility. Per interviews with staff, R1 generally used a walker but, over time, became less consistent using the walker inside the room and required redirection. Staff (S2) stated the facility had discussed R1’s increasing needs with the family and reviewed possible options, including hospice, a skilled nursing facility, or one-on-one care. S2 also stated the facility obtained a hospital bed so it could be lowered closer to the floor in an effort to reduce risk. S2 reported hospice services were scheduled to begin on October 01, 2025; however, R1 passed away prior to the start of hospice. Hospital records obtained documented that R1’s condition declined while hospitalized, including worsening breathing and decreasing oxygen levels, which led to transfer to the ICU. R1 was later pronounced deceased. A Record of Death documented the date of death as September 29, 2025, and listed cardiopulmonary arrest as the cause of death. Based on the evidence gathered through interviews and record reviews, there is insufficient evidence to support the allegation that R1’s falls were caused due to neglect. Because the preponderance of evidence has not been met, the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and confidential names list was provided to the facility's Case Manager: April Pena who signed on this report.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

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