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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006452
Report Date: 08/20/2025
Date Signed: 08/20/2025 12:35:37 PM

Document Has Been Signed on 08/20/2025 12:35 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 CAREFACILITY NUMBER:
306006452
ADMINISTRATOR/
DIRECTOR:		DUSUN LEEFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 199CENSUS: 194DATE:
08/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:02 AM
MET WITH:Sammy LeeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of delivering finding regarding case management conducted on March 07, 2025. LPA Haddadin was greeted by Assistant Executive Director, Sammy Lee who granted access to the facility, at which time the purpose of the visit was explained. On March 03, 2025, the Regional Office received a self-reported unusual incident report from the facility reporting the hospitalization of Resident 1 (R1) resulting in a bone fracture. A case management health and safety visit was then completed on March, 07th, 2025. The investigation determined as follows:
A review of facility and medical records established that Resident 1 (R1) has a documented history of Parkinson’s Disease with progressive physical decline, intermittent confusion, and Mild Cognitive Impairment, as reflected in a Physician’s Report dated May 10, 2022. Internal Incident Reports from October of 2024 to February 12, 2025, show that R1 experienced at least eight unwitnessed falls despite existing fall-risk measures developed by the Assisted Living Waiver Program (ALW). A review of R1's Individual Service Plan assessed by the dated February 6, 2025, to August 6, 2025, R1 was identified as having poor safety awareness and being at high risk for falls. A fall mitigation plan had been developed by the ALW and recommended to manage these risks. {***CONTINUE 809C***}
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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: 08/20/2025
NARRATIVE
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 Per review of R1’s file, the facility failed to conduct an appraisal of R1’s needs.
The most recent unwitnessed fall occurred on February 12, 2025, around 10 A.M. Following the fall, facility staff contacted R1’s hospice agency. Hospice agency notes dated February 12, 2025, document that a hospice nurse visited R1 at 1:15 P.M. During the visit, R1 was alert but confused, able to communicate, and reported severe, constant pain in the left arm and shoulder, grimacing with movement. Assessment revealed swelling in the left anterior shoulder, but no visible bruising was present at that time. Although R1 could move and bend the shoulder slowly, it caused significant discomfort. Hospice ordered pain medication for R1 and instructed staff to monitor for worsening pain and to contact hospice if medication was not effective. Photographic evidence from February 14, 2025, depicted significant bruising and edema on R1’s left upper extremity. Facility staff notes on February 14, 2025, at 7:40 p.m. documented a call from MedTech (MT) to the Administrator requesting transfer for hospital evaluation; however, after consulting with R1’s hospice doctor, the decision was made to keep R1 at the facility. Hospice nurse assessed R1 and noted shortness of breath, significant pain, and swelling in the left upper extremity (LUE) and bruising from the shoulder to the elbow. R1 was found lying in bed and was unable to move the left arm, an observed decline from two days earlier, when limited movement was still possible. Pain was reported as severe, consistent with a pain scale of 10/10 with movement. R1 required complete assistance with all activities of daily living (ADLs), including feeding, bathing, dressing, toileting, turning, and mobility. Hospice agency ordered an X-ray and provided new orders for medication and treatment for R1. R1’s family was informed and agreed not to transfer R1 to the hospital, however the R1 was not conserved and had no POA. Even though Hospice agency instructed facility staff to apply an ice pack and monitor changes and report them, the facility staff did not complete any further post-fall monitoring observations or progress notes from February 14 through February 22, 2025. On February 18, 2025, a portable X-Ray was executed and the R1 was diagnosed with an injury at the top of the upper arm bone and a shoulder dislocation. After consulting with an orthopedic doctor, it was decided that a closed reduction could be attempted. (Per Mayo Clinic definition a Closed reduction is a procedure where some gentle maneuvers might help move the shoulder bones back into position.***{CONTINUE 809C***}
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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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: 08/20/2025
NARRATIVE
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 Depending on the amount of pain and swelling, a muscle relaxant or sedative or, rarely, a general anesthetic might be given before moving the shoulder bones. When the shoulder bones are back in place, severe pain should improve almost immediately.) R1 was given pain medication, and the reduction was performed. A follow-up X-ray was ordered to confirm successful reduction. By February 21, 2025, a repeat X-ray showed that the shoulder was still dislocated. Plans were made to take R1 to an orthopedic clinic the next day. However, on February 22, 2025, R1 was transferred to the hospital by a family member. Medical record from the Hoag Hospital Emergency Center dated February 22, 2025, listed R1’s diagnoses as a dislocation of the left shoulder joint, a closed fracture of the head of the left humerus, and an acute embolism and thrombosis of the deep vein of the left upper extremity.
Interviews with four staff conducted during the investigation denied any failure to provide adequate supervision or to initiate a timely medical response following the falls of R1; however, the facility’s Internal Incident Report from February 22, 2025, states that R1 complained of severe left arm pain immediately following the fall. Despite this, facility staff notified hospice instead of contacting 911.
Based on the preponderance of evidence, the facility did not provide care and supervision and failed to seek timely medical attention.
The facility is being cited for violating Title 22, Division 6 of the California Code of Regulations. An immediate civil penalty was assessed per LIC421IM. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted and a copy of this report along with LIC809-D, Appeal Rights, Civil Penalty Assessment -LIC 421 IM and the LIC 811, identifying confidential names were provided.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 12:35 PM - It Cannot Be Edited


Created By: Samer Haddadin On 08/20/2025 at 10:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006452

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
87465(g)

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87465(g) Incidental Medical and Dental. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including
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Licensee will conduct training to all facility staff on when to call emergency services to residents who are in need of immediate hospitalization and well send traning log to LPA by POC due date
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but not limited to, an apparent life-threatening medical crisis This requirement was not met as evidence by: Licensee did not seek immediate medical attention following R1 sustaining
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 an unwitnessed fall on February 12, 2025, despite of persistent pain, developing swelling, bruising and losing the ability to complete ADLs, which poses an immediate risk to resident’s health in care.
Type A
08/20/2025
Section Cited
CCR87464(f)(1)

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87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Licensee will ensure re-evaluate residents and document all updates when incidents of injures and such occurs to ensure the safety od residents in care.
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This requirement was not met as evidenced by: Licensee did not re-evaluate care needs following R1 sustaining eight falls within a five month period resulting in R1 being hospitalized with shoulder
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 and humerus fractures. This poses an immediate risk to resident’s health in care
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 12:35 PM - It Cannot Be Edited


Created By: Samer Haddadin On 08/20/2025 at 11:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006452

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
87463(b)(1)(E)

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87463(b)(1)(E) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented
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Facility will sel-certify the understanding of reappraisals for residents who require an updated Needs& services plan and e mail LPA the by POC due date
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 as specified in Section 87466, Observation of the Resident. This requirement was not met as evidence by: Licensee did not update needs and services plan as required by section above.
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 This poses an immediate risk to resident’s in health care.

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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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