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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850397
Report Date: 09/06/2024
Date Signed: 09/06/2024 10:42:42 AM


Document Has Been Signed on 09/06/2024 10:42 AM - 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:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Administratoer - Jennifer MillerTIME COMPLETED:
11:19 AM
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 At 9:00am on 09/06/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conducted a case management visit pertaining to a Serious Incident Report (SIR) submitted by the facility on 09/05/2024 of suspected physical abuse by staff. LPA noted that Paso Robles Police Department, Officer V. Gomez conducted on site interviews on 09/04/2024, with report (report #24-3047) and Adult Protective Services were notified.

LPA conducted interviews of Staff (S) and Residents (R). LPA noted that 2 of 6 Residents were able to provide interviews. Of the 2 Residents who were able to provide interviews, both residents stated they feel safe with care staff and have no issues with the facility. R2 stated that they commonly have seizures and the care provided by facility care staff is very good at all times. Interviews of S1 and S2 both stated that they have had no complaints of Residents of other staff of any issues, and not aware of any staff miss treating Residents. Administrator and LPA conducted a full medication audit of R1's medication, LPA noted that medications are administered as prescribed and medication is documented and accounted for during this audit.

LPA requested and collected documentation, and may request more documentation as needed.

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: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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