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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700136
Report Date: 09/07/2021
Date Signed: 09/07/2021 02:01:06 PM

Document Has Been Signed on 09/07/2021 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HARVEY ESTATEFACILITY NUMBER:
342700136
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:9812 HARVEY ROADTELEPHONE:
(209) 329-5689
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 3DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nicole YorksTIME COMPLETED:
02:00 PM
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On 09/07/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 12:50 PM, LPA met with Facility Manager Nicole Yorks at the entrance of the facility and explained the purpose of the visit. LPA had his temperature checked and logged.

At approximately 1:00 PM, LPA toured the physical plant with the Facility Manager. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility backyard was free of debris and had an isolation building for any COVID-19 positive cases. The facility's kitchen was free of debris and the refrigerator was stocked with meat, chicken, and egg. At 1:10 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked in the garage, along with stored PPE supplies.

At approximately 1:25 PM, LPA completed the facility tour for Infection Control with the Facility Manager. This report was reviewed with the Facility Manager. No deficiencies were cited today.

Exit interview conducted. A copy of this report will be emailed to the Facility Manager.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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