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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850398
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:26:14 AM

Document Has Been Signed on 11/14/2024 11:26 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 LIVING #2FACILITY NUMBER:
405850398
ADMINISTRATOR/
DIRECTOR:
MILLER, JENNIFER R.FACILITY TYPE:
740
ADDRESS:1520 EXPERIMENTAL STATION ROADTELEPHONE:
(626) 497-4245
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Jennifer Miller TIME VISIT/
INSPECTION COMPLETED:
01:31 PM
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At 10:30am on 11/14/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the facility annual inspection. LPA met with Administrator, Jennifer Miller announced who he is and the reason for the visit.

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 6 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 hallway. 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 reviewed staff, and resident files and reviewed medication records including Centrally Stored Medication Records (CSMR) 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 in the hallway closet. 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 care tools modules and discovered no issues, technical, violations, or citations.

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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