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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700136
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:09:27 PM

Document Has Been Signed on 10/10/2023 03:09 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: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Facility Staff, Fayez KhanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual inspection. LPA met with facility staff Fayez Khan, and explained the purpose of the visit.

LPA Valerio and Staff toured the facility to ensure compliance with Title 22 regulations. LPA observed resident bedrooms to be clean and free from debris. Bedrooms were equipped with a bed, night stand, chair, a dresser, and closet space. Bathrooms were clean and free from odors. Hot water was measured at 112.6 degrees F. The temperature inside the facility was 73 degrees F. Common areas were fully furnished. LPA observed sharps, toxins, and medications to be locked and inaccessible to residents in care. LPA observed the backyard to have an area to have outdoor visits and emergency exits were cleared. The shed in the back was observed to used for storage and/or meetings.

LPA observed 3 residents and 3 staff. Staff were assisting residents, cleaning the home, and 1 staff went out to go grocery shopping. Residents were observed walking around the facility, watching Netflix, and one resident was out at day program. LPA observed 4 resident files and 4 staff files. Resident files were current with up to date files. Staff files were observed to be up to date.

LPA requested the following documentation be sent to the Regional Office: LIC 500, LIC 308, Surety Bond, and LIC 610

Per California Code of Regulation (CCR) - Title 22, Division 6, Chapter 6, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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