Harvest Retirement

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not notify responsible party of incident Facility staff tied residents to wheelchairs

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on October 17, 2023. LPA was greeted and granted entry into the facility and met with Administrator (AD) Rose Enriquez. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not notify responsible party of incident. Regarding the allegation the following was revealed: During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated October 15, 2023, for Resident 1 (R1). Per UIIR, on October 15, 2023, R1's wife and daughter were informed about R1 excessively sweating while walking in the hallway. Per UIIR, R1 was transported to the Hospital. During the course of the interviews with staff, Staff 1 (S1) reported that unusual incidents get reported to the Medication Technician who is in charge of notifying the Responsible Party (RP). During tthe state’s words, verbatim · CDSS document, Oct 17, 2025 · control 22-AS-20231017103829

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility regarding additional information on the complaint allegation listed above. LPA explained the reason for the visit upon entry. On October 22, 2024, the department received subpoenaed medical records from West Anaheim Medical Center (WAMC) regarding Resident 1 (R1). A review of the medical records reveal R1 was diagnosed with a stroke. An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). The facility was cited per Title 22, Division 6 of the California Code of Regulations. An amended deficiency is being cited on the attached LIC9099D. An immediate Civil Penalty is being assessed today in the amount of five hundred dollars ($500). An exit interview was conducted, and a copy of this report, a copy of Civil Penalty Assessment Form and appeal rights was provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20240301162515

Allegation investigated: Staff did not meet the residents' care needs resulting in injury.

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, document review, and photo review. Regarding the complaint allegation: Staff did not meet the residents' care needs resulting in injury. During the investigation interviews were conducted with facility staff. 6 staff members denied the allegation and explained that residents are changed every two hours or as needed. LPA requested to review the incontinent care logs and it could not be found; however, Staff 1 (S1) provided an end of shift report which is a care log for the entire shift. On the end of shift report, the incontinent care was noted for each shift. Continued on LIC9099 Substantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

Allegation investigated: Staff did not treat residents with respect.

Regarding the complaint allegation: Staff did not treat residents with respect. During the investigation 5 of 7 individuals denied the allegation. Staff 6 (S6) strongly denied any staff yelling at residents’ and said that would not happen in front of them. S6 explained if they heard about this happening, they would try to catch the individual in action. Multiple staff members interviewed during the investigation explained that sometimes the caregivers do speak loudly and are encouraged to lower their voice by Staff 1 (S1). According to Staff 3 (S3) sometimes the staff get together and start to talk and sometimes it can get loud. S3 says, S1 will remind them to lower their voice. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violatiothe state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

Allegation investigated: Facility did not prevent resident from eloping. Staff did not follow the medication orders as prescribed.

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 Unfoundedthe state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

Allegation investigated: Due to lack of staff, facility did not respond to the resident's call timely.

On March 11, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA was greeted and granted entry by Assisted Living Waiver Program Director (PD) Rose Enriquez. PD Enriquez made a telephone call to Administrator (AD) Ginger Po who stated they could not meet for today's visit. LPA Kim explained the purpose of the visit to AD Po and AD Po said that PD Enriquez could sign on their behalf. The investigation consisted of the following. On January 22, 2025, LPA Kim conducted initial visit. LPA obtained records and interviewed ten staff (S1-S10) and nine residents (R1-R9). The investigation revealed the following: Allegation: Due to lack of staff, facility did not respond to the resident’s call timely. It is alleged that around 5:45 AM, a resident (R1) was crying out for help because the resident had fallen out of bed and could not reach their pendant. Another resident attempted to find staff to assithe state’s words, verbatim · CDSS document, Mar 11, 2025 · control 22-AS-20250115130302

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff handled resident in a rough manner, resulting in resident sustaining a bruise

Licensing Program Analyst (LPA) Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation made February 6, 2024. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Staff handled resident in a rough manner, resulting in resident sustaining a bruise The investigation consisted of interviews and document review. Interviews with 4 of 5 individuals confirmed Resident 1 (R1) sustained bruising to the left arm. Document review and interview confirmation revealed that R1 complained to Staff 4 (S4) about pain to the arm after being showered by Staff 2 (S2). S4 reported the information to Staff 1 (S1). According to S1, it was reported that R1 was on the bed when S2 yanked or pulled R1’s arm because it was time to shower. According to S1, after gathering details on the incident, an in-service training was conducted and an Employee Warning Notice signed and dated by S2 and Staff 3 (S3) was issued to S2 for thethe state’s words, verbatim · CDSS document, Jun 10, 2024 · control 22-AS-20240206145710

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received March 1, 2024. LPA Haley was greeted by staff and explained the reason for the visit upon entry. During the visit, LPA Haley conducted staff interviews and collected relevant documents. Regarding the allegation: Staff did not seek medical attention for resident in a timely manner. 2 of 2 staff interviewed confirmed Resident 1 (R1) had a change in condition observed by staff and was not assessed or sent out for an evaluation after the change in condition. Staff interviews revealed sometime during the morning of February 22, 2024, Staff 3 (S3) observed Resident 1 (R1) weak and unable to stay balanced. R1 was given a wheelchair and S3 spoke to Staff 4 (S4) regarding the change in condition. However, R1 was never assessed and never sent out to be evaluated regarding the change in condition. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Mar 5, 2024 · control 22-AS-20240301162515

Allegation investigated: Facility staff are not keeping residents clean Facility is not maintaining a comfortable temperature for residents in care

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Director of Operations Rachelle Reyes. LPA explained the reason for the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegations, the following was revealed: Seven of eight individuals interviewed denied the allegations. During interviews conducted with residents it was reported that staff assist the residents to stay clean and/or that staff are helpful. Per Resident 1 (R1) he does not need much assistance but that staff assist him with washing his clothes, towels and bedding in order to keep his personal space clean. During interviews conducted with staff, Staff 1 (S1) reported that residents are schedule for three showers pthe state’s words, verbatim · CDSS document, Oct 26, 2023 · control 22-AS-20231017103829