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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802263
Report Date: 12/16/2023
Date Signed: 12/16/2023 03:47:51 PM


Document Has Been Signed on 12/16/2023 03:47 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: 6DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Administrator - Jennifer MillerTIME COMPLETED:
04:00 PM
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At 1:20pm on 12/16/2023, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA also delivered final findings to a complaint of this facility on a separate report on this date.

LPA toured facility with Administrator. 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 tested within regulation parameters of 105*-120* (f) . Residents’ rooms are appropriately furnished with adequate lighting and linin. 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. Infection control plan and emergency disaster plan were reviewed by LPA and Administrator. LPA conducted a sample medication audit and Centrally Stored Medication Records review (CSMR). LPA noted that the facility was clean and in good repair with no obstruction in the hallways or any exits/entrances. LPA noted that no citations or violations were discovered during the full facility walking tour.
Administrator and LPA conducted a full review of the annual care tools module. LPA noted that noted that no technical, violation, or citations were issued as a result of the full review of the annual care tools modules. LPA noted that the full annual facility inspection there were not violations or citations issued.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2023
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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