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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006452
Report Date: 01/22/2026
Date Signed: 01/22/2026 02:54:27 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
12/11/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251211092635
FACILITY NAME:HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306006452
ADMINISTRATOR:DUSUN LEEFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(714) 459-3353
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 197DATE:
01/22/2026
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Susan Lee
Shirley Mazariegos		TIME COMPLETED:
11:59 AM
ALLEGATION(S):
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Staff did not notify authorized representative of incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to investigate the complaint allegation listed above. LPA Haley explained the reason The complaint investigation consisted of interviews and document review.

Regarding the allegation: Staff did not notify authorized representative of incident
During the investigation, Staff 1 (S1) provided an incident report dated December 11, 2024 regarding Resident 1’s (R1) fall. On the report it indicates which family member was called, and what time the family member was called. There’s also a note on the incident report that states multiple calls were made to the family member and the phone either goes straight to voicemail or that number is out of service.

Additional document review revealed an email from a family member of R1 dated December 12, 2024, at
Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
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-20251211092635
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: HARBOR HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006452
VISIT DATE: 01/22/2026
NARRATIVE
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5:26 PM; in the email from the family member, it’s clear the family member was made aware of the incident regarding R1 as the family member was requesting video of the incident that took place the previous day.

Based on the information gathered through document review, the allegation is deemed unfounded, meaning the allegation is false, could not have happened and/or is 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: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2