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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 03/20/2025
Date Signed: 03/20/2025 09:59:56 PM

Substantiated


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
03/12/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250312162715
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:
03/20/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Rose EnriquezTIME COMPLETED:
04:59 PM
ALLEGATION(S):
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Staff did not meet the residents' care needs resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, document review, and photo review.

Regarding the complaint allegation: Staff did not meet the residents' care needs resulting in injury.

During the investigation interviews were conducted with facility staff. 6 staff members denied the allegation and explained that residents are changed every two hours or as needed. LPA requested to review the incontinent care logs and it could not be found; however, Staff 1 (S1) provided an end of shift report which is a care log for the entire shift. On the end of shift report, the incontinent care was noted for each shift.

Continued on LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 3
Control Number 22-AS-20250312162715
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: 03/20/2025
NARRATIVE
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According to S1 and other staff members who were interviewed during the investigation explained that Resident 1 (R1) deals with on and off again rash like irritation to the groin area. Document review revealed that R1 is on hospice and the rash like irritation was being treated with Calomoseptine cream since January 15, 2025. The cream did not appear to be treating the rash and it was reported to the hospice nurse, and on March 14, 2025 Hospice provided an order for a new medication (Nyastatin powder) to treat R1’s rash like irritation on the groin area.

During the investigation the department received several photos of different residents that dealing with skin discolorations, rashes, and skin tears. During a phot0 review of R1’s groin area, LPA observed what appeared to be redness on all sides of the groin area with darker red spotting all around the private area. The irritated area appears to be bleeding or was bleeding as blood can be seen on the residents legs and inside the pull up. LPA Haley also received photos of Resident 2 (R2) with red spots on the tail bone area and on a private area on R2. In the photo of R2’s private area the skin appears to be broken.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250312162715
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed... The plan shall encourage... and provide for assistance in obtaining such care...
(1) The licensee shall arrange... for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not being met as evidenced by:
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Assistant Administrator stated residents evaluated by their physician so affected areas of the skin can be evaluated and treated, if needed. Assistant Administrator will provide an update on each resident via email. Further, incontinent training will be scheduled for all staff on March 25, 2025.
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Photo evidence showed three different residents dealing with skin irritation. In on photo redness was observed on the resident groin area with darker color red spots and what appeared to be blood in the residents’ pull up.
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3