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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850398
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:13:19 PM


Document Has Been Signed on 12/16/2023 01:13 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 #2FACILITY NUMBER:
405850398
ADMINISTRATOR:MILLER, JENNIFER R.FACILITY TYPE:
740
ADDRESS:1520 EXPERIMENTAL STATION ROADTELEPHONE:
(626) 497-4245
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 4DATE:
12/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Administrator - Jennifer MillerTIME COMPLETED:
01:25 PM
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 At 10:00am on 12/16/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility at the schedule time to conduct the pre-licensing inspection of the facilities change of ownership (CHOW). LPA met with Administrator Jennifer Miller to conducted the pre-licensing inspection.
Administrator and LPA conducted a full tour of the facility, and facility grounds. The facility is located in a rural area on approximately two acres which is gated. The facility has five bedroom, and 6 bathrooms, of which one bathroom is a common shared bathroom for residents, staff and visitors. There is a laundry room which has a refrigerator, a closed hallway that has a sink and locked cabinets where chemicals are stored. Medications are located in a locked cabinet in the kitchen island. The kitchen dining room and living room are open concept configuration. There are dual smoke detectors/carbon monoxide detectors throughout the facility and a individual carbon monoxide detector in the west hallway all currently functional. Administrator and LPA reviewed emergency disaster plan, infection control plan and fire clearance review. LPA noted that the facility has well water tank and passed regulatory inspection for initial licensing inspection. 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 the facility is clean and in good repair. LPA noted that all exits and hallways were free and clear from obstructions.
Administrator and LPA conducted a full review of the pre-licensing care tools modules and discovered no issues, technical, violations, or citations.
LPA conducted the full Composition III (COMP III) review with Administrator Jennifer Miller.
At this time the pre-licensing inspection and COMP III component has been completed and LPA Jeffries 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: 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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