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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 02:57:29 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
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:
12:00 PM
MET WITH:Susan Lee
Shirley Mazariegos		TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff did not notify authorized representative of medication changes
INVESTIGATION FINDINGS:
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Regarding the allegation: Staff did not notify authorized representative of medication changes

During the investigation, interviews were conducted with 6 individuals including facility staff and a medical professional. During an interview with Witness 1 (W1), it was confirmed that on December 6, 2024, one of R1’s medications was changed from being administered once a day, to being administered two times per day according to W1. During interviews with facility staff, it was confirmed R1’s family was not notified regarding the medication change.

Based on the evidence gathered through interviews, the preponderance of evidence standard has been met, therefore, the allegation above is found to be SUBSTANTIATED. A violation is 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.
Substantiated
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2026
Section Cited
CCR
87463(f)
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87463(f) Reappraisal
(f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record.
This requirement is not being met as evidenced by:
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Facility representative agrees to review the regulation requirement and send a signed statement of acknowledgement and understanding to LPA Haley. Facility representative agrees to email the POC to LPA Haley by 5:00pm on the POC due date.
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Facility staff failed to notify Resident 1 (R1) family of a medication change ordered December 6, 2024. This poses a potential health and safety risk for residents 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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