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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700136
Report Date: 10/04/2022
Date Signed: 10/14/2022 09:21:46 AM

Document Has Been Signed on 10/14/2022 09:21 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, 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: 4DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brittney Chaves, House ManagerTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) R. Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with House Manager, Brittney Chaves, Administrator is Hanif Khan and he currently holds a certificate (#600266735) that expires on 12/04/2023. The facility’s fire clearance was approved for four ambulatory of which one may be non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 4 bedrooms are occupied by the clients and zero bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 69-degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110-degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day nonperishables and 2-day perishables foods.
Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on April, 2022.. Emergency Disaster Plan was last posted on 09/07/22.
Resident Medication Administration Record was reviewed for continued use of the two person protocol. Staff initial and date both medication packets and hardcopy records for each resident.
No deficiencies were cited during this inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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