Harbor Heights Assisted Living and Memory Care

Facility personnel sufficiency and competence

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 2/11/25, on 1/21/25 at 10:30 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.

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: 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.

Facility personnel sufficiency and competence

87411(a)"...agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services." This requirement is not being met as evidenced by record review and interviews: Licensee did not provide the one-on-one care for residents which poses an immideate health and safety to residents in care

Document required significant condition changes

87463(b)"reappraisal shall document changes in the resident's physical, mental, cognitive, behavioral, or functional condition,as specified in Section 87466" This requirement is not being met as evidenced by record review. Licensee did not maintain updated reappraisal for four out of four residents which poses a potential health and safety to residents in care

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including but not limited to, an apparent life-threatening medical crisis This requirement was not met as evidence by: Licensee did not seek immediate medical attention following R1 sustaining

87463(b)(1)(E) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met as evidence by: Licensee did not update needs and services plan as required by section above.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Licensee did not re-evaluate care needs following R1 sustaining eight falls within a five month period resulting in R1 being hospitalized with shoulder

87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility....} 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.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in water temperature measured at 93.9 DF and 94.1 DF which poses an immediate health, safety risk to persons in care.

87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility....} 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.

87555 General Food Service Requirements(20) Food preparation equipment shall be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies.Based on observations, the Licensee did not comply with the section cited above due to a 2-burner stove in the kitchen protruding 17.5 inches into the aisle where kitchen staff work and move.

Food storage temperature control requirements

87555 General Food Service Requirements(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.Based on observations, the Licensee did not comply with the regulation cited above due to the refrigerator temperature being set between 42-43 degrees F. This creates a potential health risk to persons in care.

Food storage temperature control requirements

87555 General Food Service Requirements(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.Based on observations, the Licensee did not comply with the regulation cited above due to the refrigerator temperature being set to 46.8 degrees F. This creates a potential health risk to persons in care.

Rapid-growth perishable foods must be covered

87555 General Food Service Requirements(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. Based on observations, the Licensee did compy with the regulation cited above due to LPA observations of five perishable foods being uncovered in the kitchen.

87555 General Food Service Requirements(20) Food preparation equipment shall be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies.Based on observations, the Licensee did not comply with the section cited above due to a 2-burner stove in the kitchen protruding 17.5 inches into the aisle where kitchen staff work and move.

Certified administrator requirements and substitute coverage

87405(a)Administrator - Qualifications and Duties:(a)All facilities shall have a qualified and currently certified administrator... This requirement is not being met as evidenced by, through a record review and interviews it was demonstrated that the facility does not a qualified and currently certified administrator. This poses a potential health and safety risk to residents in care.