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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802263
Report Date: 06/08/2022
Date Signed: 06/08/2022 08:10:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220603140415
FACILITY NAME:HARVEST SENIOR LIVING LLCFACILITY NUMBER:
405802263
ADMINISTRATOR:FARIA, DIORENE RFACILITY TYPE:
740
ADDRESS:805 EXPERIMENTAL STATION RDTELEPHONE:
(805) 369-2261
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Alvaro FariaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff are not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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 At 8:00pm on 06/08/2022, Licensing Program Analyst (LPA) Jeffries conducted a 10-day Complaint visit to the facility above. LPA met with Administrator Alvaro Faria and explained the purpose of the visit.

On the allegation, “Facility staff are not following COVID-19 protocols.” LPA interviewed credible witness (W1) which revealed that Staff 1 (S1) was not wearing a mask. The other staff (S2) were present. A visitor (V1) was also present, not wearing a mask, but did put one on without hesitation." according to the RP.

Exit interview conducted, deficiency cited, copy of report and appeal rights provided to Licensee/Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220603140415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARVEST SENIOR LIVING LLC
FACILITY NUMBER: 405802263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 (a)(2) Personal Rights of Residents in all Facilities; To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Provide training records with all staff signatures to CCL by 06/17/2022.
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 Based on interviews and observation the licensee did not ensure all staff were wearing face coverings in the facility which poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2