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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850397
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:11:40 PM


Document Has Been Signed on 01/19/2024 02:11 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 LIVINGFACILITY NUMBER:
405850397
ADMINISTRATOR:MILLER, JENNIFER RFACILITY TYPE:
740
ADDRESS:805 EXPERIMENTAL STATION ROADTELEPHONE:
(626) 497-4245
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Jennifer MillerTIME COMPLETED:
01:15 PM
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At 9:00am on 01/19/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility at the scheduled time to conduct the pre-licensing inspection of the facilities change of ownership (CHOW). LPA met with Administrator Jennifer Miller to conduct the pre-licensing inspection.

Administrator and LPA conducted a full tour of the facility, and facility grounds. There is a large fenced backyard with garden, ample seating, awning for shade for residents and guest. This facility has 5 resident bedrooms, and 3 resident bathrooms. There are two living rooms, a kitchen, dining room and laundry room. The facility utilized a locked mobile medication cart that normally kept in the back of the dining room area. LPA observed all resident bedrooms and bathrooms all found to be compliant with regulation standards. LPA observed full facility and facility grounds and found all to be compliant with regulation standards. LPA noted that there is a complete first aide kit on hand at the facility. LPA noted that the facility food supply that currently meets or exceeded licensing standards of perishable and non-perishable foods. . LPA noted that all exits and hallways were free and clear from obstructions. LPA noted that there are smoke detectors throughout the facility and a carbon monoxide detector that are all functional and working. LPA noted that the facility is clean and in good repair

Administrator and LPA conducted a full review of the pre-licensing care tools modules and discovered no issues, technical, violations, or citations. LPA noted that this facility, under the current Administrator had just passed the annual inspection on 12/16/2023, where the full annual inspection control tools module was reviewed with not technical, violations, or citations.

LPA conducted the full Composition III (COMP III) with Administrator Jennifer Miller on 12/16/2024.

At this time the pre-licensing inspection and COMP III component has been completed and LPA Jeffries and has no objections to the change of ownership (CHOW) licensing of this facility.

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: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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