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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209236
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:01:52 PM


Document Has Been Signed on 12/08/2023 02:01 PM - 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:HARLOCK ASSISTED LIVING, LLCFACILITY NUMBER:
157209236
ADMINISTRATOR:BARAJAS, JUDITHFACILITY TYPE:
740
ADDRESS:7214 BOULDER FALLSTELEPHONE:
(818) 422-5898
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 4DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dustina SherwoodTIME COMPLETED:
02:21 PM
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On 12/08/2023, Licensing Program Analyst (LPA) M. Medina made an unannounced Annual Required Inspection. LPA was allowed entrance by Administrator, Dustina Sherwood. Also present was licensee, Greg Harlock.

Currently, four (4) residents in care. Facility tour began in resident bedrooms. Rooms observed to have all required accommodations. All areas of the facility have sufficient lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 120 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed adequate food supply for the residents in care. LPA observed leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. Medications observed to be locked in cabinet in kitchen. All medications observed to have original labels and observed to be administered as prescribed.

Smoke Alarms tested observed operational at time of inspection. Carbon monoxide detector present and observed operational at time of inspection. Fire extinguisher has a purchase date of 12/08/23. All cleaning supplies observed to be locked and secured in laundry room.

Outside areas toured. All exits open freely and observed to be free of obstruction. No hazards observed.

Report continued on 809-C
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HARLOCK ASSISTED LIVING, LLC
FACILITY NUMBER: 157209236
VISIT DATE: 12/08/2023
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Resident and staff files reviewed.

Facility to submit updated LIC 308, LIC 309, LIC 500, and LIC 610E, LIC 9020, Certificate of Liability Insurance and Administrator packet to Fresno Regional Office no later than 1/29/2023.

No deficiencies cited.

Exit interview conducted, and copy of report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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