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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 10:03:09 PM

Unfounded


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:
05:00 PM
MET WITH:Rose EnriquezTIME COMPLETED:
08:59 PM
ALLEGATION(S):
1
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9
Facility did not prevent resident from eloping.
Staff did not follow the medication orders as prescribed.
INVESTIGATION FINDINGS:
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3
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5
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7
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9
10
11
12
13
Regarding the complaint allegation: Facility did not prevent resident from eloping.

During the investigation it was discovered Resident 3 (R3) could not be located on the morning or March 8, 2025. Facility staff went to the cameras and after reviewing the footage it was discovered the R3 walked out of the facility after signing themself out around 8:00am. R3 indicated that they would be going to the hospital. After the resident did not return later in the day the staff contacted local hospital to see if the resident had been admitted. After being unable to locate R3, S1 contacted local Police and filed a missing persons report.
On March 14 Staff 2 (S2) received a call from the Orange County Public Guardian (OCPG) who explained they received a call form someone with the New York Police Department and R3 was located in New York. Document review revealed that R3 does not have dementia or MCI and can leave the facility unassisted.

Continued on LIC9099C
Unfounded
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 2
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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32
Regarding the complaint allegation: Staff did not follow the medication orders as prescribed.

During the investigation it was discovered R2 was being seen by a Home Health Nurse who was treating the irritated areas to R2’s tailbone and private area with barrier cream and off-loading. According to Staff 1 (S1) rotating the resident was important. Staff was advised to rotate the resident at least every two hours. Home Health came to treat the affected area once a week. However, the Home Health Nurse was in the facility daily and would see R2 upon request if needed, according to S1.

Based on the information gathered through interviews and document review, the following allegations: Facility did not prevent resident from eloping, and Staff did not follow the medication orders as prescribed are deemed unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted, and a copy of this report was 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 2