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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802263
Report Date: 10/22/2022
Date Signed: 10/22/2022 12:56:12 PM


Document Has Been Signed on 10/22/2022 12:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
10/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alvaro Faria/LicenseeTIME COMPLETED:
02:15 PM
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 At 10:00pm on 10/22/2022, Licensing Program Analyst (LAP) arrived at the facility unannounced to conduct the annual infection control inspection. LPA met with Licensee Alvaro Faria and announced the reason for the visit.
Licensee and LPA toured facility. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning and are hardwired throughout the facility. Fire extinguisher was fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 70 degrees F. Hot water temperature were within regulation parameters (95* - 120*f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and mass casualty plan is readily available located in the facility kitchen. LPA observed at least a 30 day supply of PPE on hand in the garage and observed liquid soap and paper towels in all the bathrooms. LPA was properly screen when entering the facility. The facility is clean and well maintained, there were no obstructions to exits. LPA noted that there were no visible regulation violations on this cursory tour inspection and not deficiencies or citations were issued as a part of the cursory tour of the facility,.
Licensee and LPA conducted the infection control module of the annual inspection. LPA noted that there were no deficiencies found and no citations issued on the infection control module of the annual inspection.

Exit interview, report singed, and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
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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