306005207-2-4-2026-22-AS-KSGH-DUWRWG-20260610132304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005207
Report Date: 02/04/2026
Date Signed: 02/04/2026 01:27:33 PM

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
01/27/2026 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260127144048

FACILITY NAME:	HARVEST RETIREMENT		FACILITY NUMBER:	306005207
ADMINISTRATOR:	ROSE ENRIQUEZ		FACILITY TYPE:	740
ADDRESS:	9011 KNOTT AVE		TELEPHONE:	(714) 821-4130
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	106	CENSUS: 74	DATE:	02/04/2026
		UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Rose Enriquez		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not notify resident's family member of resident's change of condition.
Staff did not report resident's death to responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to begin the investigation into the complaint allegations listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review.

Regarding the allegation: Staff did not notify resident's family member of resident's change of condition.

During the investigation 4 of 4 individuals interviewed provided information that contradicts the complaint allegation. During interviews it was discovered that Resident 1 (R1) did not have much involvement from family in regards to the resident’s care needs. It was discovered that R1 did have a sibling but R1’s sibling was not involved in R1’s care at all. According to S3, R1’s sibling came to the facility several years ago to drop off mail for R1, due to a request made by the facility. According to S3, that was the only time the sibling came to the facility.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260127144048

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: 02/04/2026

NARRATIVE

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S3 says the facility contacted the sibling after the mail was dropped off and during the conversation with R1’s sibling, the sibling asked to not be contacted by the facility because they had a lot of things going on in their personal life. S3 said, the facility attempted to contact R1’s sibling again after the second contact was made, and the siblings’ telephone number was disconnected.

According to Staff 1 (S1) and Staff 2 (S2), R1’s siblings’ telephone number was either disconnected or off since both staff members were hired. One staff members was hired in 2021, and the other was hired in 2024. According to both members of the staff, the number on file for R1’s sibling never worked since they were hired.

Regarding the allegation: Staff did not report resident's death to responsible party.

During the investigation 3 of 4 individuals interviewed provided information that contradicts the complaint allegation. According to S2, when R1 passed, a call was made to R1's sibling but the phone didn’t ring or anything. According to the staff, the number was off or disconnected because the phone didn't ring or anything. A review of the incident report sent to the department on October 7, 2025, stated R1 does not have any family on file. According to the incident report, R1’s hospice provider was notified of a possible change in condition. The hospice provider showed up to the facility a very short time later and pronounced R1 deceased.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.

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: 02/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

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