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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006452
Report Date: 08/20/2024
Date Signed: 08/20/2024 06:01:23 PM


Document Has Been Signed on 08/20/2024 06:01 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306006452
ADMINISTRATOR:DUSUN LEEFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 194DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Susan Lee - Executive DirectorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 8/20/2024, LPA Dwayne Mason Jr. conducted a Case Management visit to the facility. LPA arrived and was greeted and granted entry by Executive Director Susan Lee. LPA explained the nature of the inspection.

LPA toured the facility and observed an aisle in the kitchen between appliances and food storage. Facility staff occupy this aisle while preparing food. LPA measured aisle to be 43.5 inches wide. LPA observed a two-burner stove that extends into the aisle by 17.5 inches. LPA measured the distance from the front face of the two-burner oven to the shelf of food across from it. The aisle measured 26 inches.

LPA obtained photos.

Based on observations, one citation is being issued. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 06:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
87555(b)(20)

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87555 General Food Service Requirements
(20) Food preparation equipment shall be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies.

Based on observations, the Licensee did not
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Executive Director stated they will move or remove the two-burner stove from the facility by the assigned POC due date. LPA will verify the correction at a plan of corrections visit.
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comply with the section cited above due to a 2-burner stove in the kitchen protruding 17.5 inches into the aisle where kitchen staff work and move.
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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