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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006452
Report Date: 02/21/2025
Date Signed: 02/21/2025 01:48:29 PM

Document Has Been Signed on 02/21/2025 01:48 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306006452
ADMINISTRATOR/
DIRECTOR:		DUSUN LEEFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 199CENSUS: 193DATE:
02/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:22 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Case Management - Deficiencies visit. LPA arrived at the facility was greeted and granted entry by Administrator (AD) Susan Lee.
LPA explained to AD that this visit is in regards to a flagged incident report that the facility had sent over our regional office on 2/11/2025.
The incident report took place on 01/21/2025 stated that at 10:30 AM a dementia resident (R1) had eloped that facility. according to the incident report, the facility called 911 and at 10:50 AM a police helicopter located the resident about 1.2 miles from the facility. LPA interviewed the staff (s1) who was on duty dining the incident, as well as AD. It was determined that facility lacked of care and supervision to the resident.
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Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 02/21/2025 01:48 PM - It Cannot Be Edited


Created By: Samer Haddadin On 02/21/2025 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
87705(e)(5)

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87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility....}
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AD will retrain staff members and make sure the front Reception is covered and has staff at all times
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Based on observation interviews, record review, the licensee did not in sure the safety of the resident who eloped the facility which poses an immediate Health and safety to persons in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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