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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209236
Report Date: 10/15/2024
Date Signed: 10/15/2024 07:42:44 PM

Document Has Been Signed on 10/15/2024 07:42 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HARLOCK ASSISTED LIVING, LLCFACILITY NUMBER:
157209236
ADMINISTRATOR/
DIRECTOR:		SHERWOOD, DUSTINAFACILITY TYPE:
740
ADDRESS:7214 BOULDER FALLSTELEPHONE:
(818) 422-5898
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 5DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:29 PM
MET WITH:Dustina SherwoodTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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On 10/15/2024, Licensing Program Analyst (LPA) M. Medina made an unannounced Annual Required Inspection. LPA arrived, introduced self, and stated purpose of visit. LPA was allowed entrance by Administrator, Dustina Sherwood.

Currently, five (5) residents in care. The facility is a 5 bedroom, 2 bathroom home. Facility toured with Administrator, facility observed to be clean, well lit, odor free, and odor free. Resident bedrooms are all private. All resident bedrooms observed to have required accommodations. All common areas of the facility have sufficient lighting and seating for all residents in care. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water measured at 114 degrees F. Tour of kitchen conducted. LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for the residents in care. Medications observed to be locked in cabinet in kitchen. All medications observed to have original labels and observed to be administered as prescribed.

Carbon monoxide detector and smoke detectors tested and observed operational at time of inspection. Fire extinguisher has a purchase date of 12/12/23. All cleaning supplies observed to be locked and secured in laundry room.

Outside areas toured. All exits open freely and observed to be free of obstruction. No hazards observed.

Resident and staff files reviewed. Facility to submit updated LIC500, LIC9020, Certificate of Liability Insurance

No deficiencies cited. Exit interview conducted, and copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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