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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208918
Report Date: 06/28/2022
Date Signed: 06/28/2022 11:01:35 AM


Document Has Been Signed on 06/28/2022 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:HARVEST AT FOWLER, THEFACILITY NUMBER:
107208918
ADMINISTRATOR:ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:36CENSUS: 24DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Administrator Alex ZaninTIME COMPLETED:
11:15 AM
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On 6/28/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA met with Administrator Alex Zanin and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Facility staff observed with facial coverings.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed in the common bathrooms by the sink. Bedrooms are single occupant. Food supply was checked and there appeared to be an adequate supply. Fire extinguisher in kitchen was last serviced on 3/16/2022 and was fully charged. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Staff records were reviewed for good health.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 6/30/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E),
Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site and printed copy provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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