<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600673
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:59:52 PM

Document Has Been Signed on 07/06/2023 03:59 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HARVEST RESIDENTIAL CARE HOMEFACILITY NUMBER:
198600673
ADMINISTRATOR:FABIAN, SHIELA ANAFACILITY TYPE:
735
ADDRESS:16302 HARVEST AVENUETELEPHONE:
(323) 469-3432
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Administrator Shiela FabianTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. LPA was met by Staff Samuel Bachillar and the purpose of the visit was explained. Administrator Shiela Fabian arrived shortly after.

The following were observed/inspected:

Physical Plant: The facility is a single story house and located in a residential neighborhood. The home is vendorized through the Harbor Regional Center (HRC). It is licensed to serve four developmentally disabled, adult clients ages 18-59, of which one can be non-ambulatory. The facility consists of four (4) client bedrooms, two bathrooms, one live in staff room, kitchen, laundry area, dining room and a detached garage. Client bedrooms are for (1) client each and have required furniture per Title 22. The two (2) client bathrooms observed are clean and operational. The hot water temperature in the two bathrooms was measured within title 22 regulations. The food supply in the kitchen and pantry has at least two days perishable and seven days non perishable food. The front and back yard are free of debris and obstructions. The back yard has shaded area with for client use. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The smoke detectors and carbon monoxide detectors are located in each residents bedrooms and common area and they are working properly. MEDICATION: Medications are stored, locked and inaccessible to clients. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations, Infection Control Plan, and Disaster plan is maintained at the facility. Operating telephone was observed and available for resident use. RECORD REVIEW: LPA reviewed four (4) client files, four(4) client medications, and six (6) staff files. (3) of (4) Clients are at day program and were unavailable for interviews.

Visit completed with Inspection Tool and no deficiencies are being cited on todays visit. Exit interview conducted with Administrator Sheila and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1