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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 03/11/2025
Date Signed: 03/11/2025 09:58:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
01/15/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250115130302
FACILITY NAME:HARVEST RETIREMENTFACILITY NUMBER:
306005207
ADMINISTRATOR:GINGER POFACILITY TYPE:
740
ADDRESS:9011 KNOTT AVETELEPHONE:
(714) 821-4130
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:106CENSUS: 76DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assisted Living Waiver Program Director- Rose EnriquezTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Due to lack of staff, facility did not respond to the resident's call timely.
INVESTIGATION FINDINGS:
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On March 11, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA was greeted and granted entry by Assisted Living Waiver Program Director (PD) Rose Enriquez. PD Enriquez made a telephone call to Administrator (AD) Ginger Po who stated they could not meet for today's visit. LPA Kim explained the purpose of the visit to AD Po and AD Po said that PD Enriquez could sign on their behalf.

The investigation consisted of the following. On January 22, 2025, LPA Kim conducted initial visit. LPA obtained records and interviewed ten staff (S1-S10) and nine residents (R1-R9).
The investigation revealed the following:

Allegation: Due to lack of staff, facility did not respond to the resident’s call timely.
It is alleged that around 5:45 AM, a resident (R1) was crying out for help because the resident had fallen out of bed and could not reach their pendant. Another resident attempted to find staff to assist R1, however, the resident could not find any staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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-20250115130302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HARVEST RETIREMENT
FACILITY NUMBER: 306005207
VISIT DATE: 03/11/2025
NARRATIVE
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Based on interviews, eight out of nine residents and ten out of ten staff denied the allegation that due to lack of staff, facility did not respond to the resident’s call timely, while one resident claimed due to a lack of staff, facility staff did not respond to the resident’s call timely.

S2 states the Nocturnal (NOC) shift is from 10:30 PM to 7:00 AM with 3 caregivers and 1 medication technician. The facility has three units: Unit 1 (Memory Care) has two staff, Unit 2 (Assisted Living Wing 2) has one staff, and Unit 3 (Assisted Living Wing 1) has one staff. Residents in Unit 1 need two staff members because they need constant attention. One of the staff from Unit 1 are floaters to fill in for residents in Unit 2 and Unit 3 as needed. Unit 1 has 18 residents, Unit 2 has 20 residents, and Unit 3 has 33 residents. S2 states they have enough coverage for the facility because the residents are asleep at this time. S3 states the staff are expected to respond within 5 to 10 minutes of the call light pendant being pressed by the resident.

Based on interview, R1 stated they do not recall falling or needing assistance on the night of the incident. R1 also stated that if they needed help, then they would press the pendant. R1 said their pendant has never been broken and that staff would respond right away of pressing the pendant. At the night of the incident around 5:30 AM, S5 stated they were approached by two residents about R1 calling out for help. S5 went to R1’s room and tried to assist R1 off the floor but could not lift them up from the floor. S5 called 911 and emergency services arrived and assisted R1 to bed. Based on record review, Incident Report states staff responded at 5:30 AM and assisted the resident and called 911 at 5:36 AM. The Orange County Fire Authority (OCFA) report confirms that a call was received at 5:36 AM and they arrived at the facility at 5:42 AM Client refused to go to the hospital per Incident Report.

Based on LPA’s observation during the visit on January 22, 2025, staff responded timely to a resident’s call through the call button. A caregiver responded to the call and assisted the resident in their room within 2-3 minutes. Based on Information gathered, there is no sufficient evidence to corroborate the above allegation.

Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted and a copy of the report was provided to Assisted Living Waiver Program Director Rose Enriquez.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2