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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802263
Report Date: 12/16/2023
Date Signed: 12/16/2023 03:43:11 PM

Unsubstantiated


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
10/27/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221027111722
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
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator - Jennifer MillerTIME COMPLETED:
03:43 PM
ALLEGATION(S):
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9
Facility staff tied resident to a bed overnight.
Facility staff leave residents in wet clothes and linens overnight.
Facility staff dispense the wrong medications to residents.
Facility staff are not following reporting requirements.
INVESTIGATION FINDINGS:
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At 1:20pm on 12/16/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations above to the complaint. LPA met with Administrator Jennifer Miller, announced who he is and the reason for the visit. Additionally, LPA conducted an annual facility inspection for this facility on a separate report on this day.

As to the allegations of, “Facility staff tied resident to a bed overnight.” It was alleged that staff tied resident to the bed overnight. It was discovered through interviews of Residents on 11/02/2022 that Residents 1 through 5 (R1, R2, R3, R4, and R5) all denied ever have been tied up at any time during their stay at this facility, all residents stated feeling safe in this facility and had no issues with medication, staff care, incontinence, or facility cleanliness, or with the care provided of this facility.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20221027111722
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
VISIT DATE: 12/16/2023
NARRATIVE
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Interviews of staff 1 – 4 (S1, S2, S3, and S4) on 11/02/20222, all stated that no resident has ever been tied to a bed, all residents get changed for incontinence as needed, and no medication errors have been made in 2022 that any staff is aware. LPA observations on 11/02/2022 indicated a clean facility with standard medication administration procedures with no issues. At this time there is not enough evidence to support the allegation of, “Facility staff tied resident to bed overnight” and is unsubstantiated at this time.
As to the allegation of, “Facility staff leave residents in wet clothes and linens overnight.” It was alleged that staff leave residents in wet clothes and linens overnight. It was discovered through interviews of Residents on 11/02/2022 that Residents 1 through 5 (R1, R2, R3, R4, and R5) all denied being left in wet linins or clothes or any incontinence issues in this facility, or ever have been tied up at any time during their stay at this facility, all residents stated feeling safe in this facility and had no issues with medication, staff care, or facility cleanliness, or with the care provided of this facility. Interviews of staff 1 – 4 (S1, S2, S3, and S4) on 11/02/20222, all stated that no resident has ever been tied to a bed, all residents get changed for incontinence as needed, and no medication errors have been made in 2022 that any staff is aware. LPA observations on 11/02/2022 indicated a clean facility with standard medication administration procedures with no issues. At this time there is not enough evidence to support the allegation of, “Facility staff leave residents in wet clothes and linens overnight” and is unsubstantiated at this time.
As to the allegation of, “Facility staff dispense the wrong medications to residents.” and “Facility staff are not following reporting requirements.” It was alleged that the facility dispensed the wrong medications and failed to report dispensing the wrong medications. It was discovered through interviews, documentation and LPA medication audit that on 11/02/2022 S1 -S4 had no recollection of wrong medication being dispensed at the facility. Interviews of R1-R5 on 11/02/2022 all denied being dispensed the wrong medication at any time at the facility. On 11/02/2022, LPA Jeffries conducted a medication audit and found that Centrally Stored Medication Record (CSMR) to be in line with current medication for each resident with correct medication count correlated to CSMR. At this time there is not enough evidence to support the allegations of, “Facility staff dispense the wrong medications to residents.” and “Facility staff are not following reporting requirements.” And both allegations are unsubstantiated at this time.


Exit interview, report read, and report completed.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2