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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320353
Report Date: 01/30/2023
Date Signed: 02/13/2023 03:11:52 PM

Document Has Been Signed on 02/13/2023 03:11 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HARVARD HOPE HOUSEFACILITY NUMBER:
198320353
ADMINISTRATOR:COXSOM, AMBERFACILITY TYPE:
740
ADDRESS:4239 S. HARVARD BLVDTELEPHONE:
(323) 812-0788
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 6CENSUS: 0DATE:
01/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amber CoxsomTIME COMPLETED:
12:00 PM
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On 1/30/23, at 9:00am, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a scheduled Pre-Licensing visit. LPA met with Administrator, Amber Coxsom, and explained the purpose of today's visit. The facility will be licensed at a Residential Care Facility for the Elderly and has been approved for the total capacity of six (6). Fire Safety Inspection approved four (4) nonambulatory residents and two (2) bedridden residents.

Structure The facility is a single-story home in a residential neighborhood. The facility consists of four (4) resident bedrooms, two (2) bathrooms, kitchen, dining room living room, and office and check-in area.

Physical Plant LPA and administrator toured the facility inside and out. The front door and client room four (4) have a ramp leading to the doors and all railing are secured. In the back yard there is a seating area with tables, chairs and an umbrella. On the property is an additional building that has its own address and is not part of the facility. LPA did not observe any bodies of water. LPA observed security cameras outside of the facility. All walkways are clean, clear, and free of obstructions, hazards and debris.

Bedrooms LPA walked through and checked all bedroom. Bedrooms one (1) through three (3) have been approved for four (4) nonambulatory residents. Bedroom four (4) has been approved for two (2) bedridden residents. All bedrooms contain the required furniture including beds, nightstands with lamps, dressers, chairs and closet space for individual residents. All the beds have the required linens including a mattress cover, fitted sheet, blanket, comforter and pillow.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HARVARD HOPE HOUSE
FACILITY NUMBER: 198320353
VISIT DATE: 01/30/2023
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Bathrooms Bathroom one (1) is a common bathroom and was checked by LPA. The faucets, toilet, bathtub and shower were in good repair and fully functioning. There is a cabinet in there that stores additional towels and hygiene products. The water temperature measured 114.6-degrees Fahrenheit. Bathroom two (2) is a private bathroom in bedroom four (4). The faucet, toilet, bathtub, and shower were in good repair and fully functioning. The water temperature measured 113.9- degrees Fahrenheit. There are built in cabinet where additional towels and hygiene products stored. LPA observed ample supply of hand soap, paper towels in both bathrooms. LPA observed nonskid mats in both showers and bathtubs. All safety handrails were securely fastened.

Linens and Hygiene LPA observed additional linens in each resident room closets and in the closet in the hallway. Each resident is provided with a caddy that will contain any needed toiletries. In the hall closet there is an ample supply of adult briefs and chucks. In the cabinet in bathroom one (1) there are additional toiletries items.

Kitchen LPA observed all appliances, including stove, oven, refrigerator, dishwasher, washer and dryer, to be in good working repair. LPA observed an ample supply of cutleries, pots, and pans that were in good repair. There is a locked cabinet that will contain knives and other sharps. LPA observed a 7- day supply of nonperishable foods. All cleaning products are locked in a closet in the kitchen and inaccessible to residents. LPA observed an ample supply of paper towels. The water temperature measured 116.3-degrees Fahrenheit. There is a monthly menus posted in the hallway.

Common Areas The living room has ample seating for all residents. There are magazines available for residents. There is a fireplace that has a cover over the front and is inaccessible to residents. The dining room has ample seating for all residents. There are cabinets in the dining room that have games and activities available for residents. Posted in the hallway is the monthly activity calendar and daily schedule. All common areas have ample lighting and bright nightlights in the hallway. All walkways are clean and clear of obstructions and hazards.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HARVARD HOPE HOUSE
FACILITY NUMBER: 198320353
VISIT DATE: 01/30/2023
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Safety LPA observed and tested five (5) smoke/carbon monoxide detectors in the facility. There are two (2) fully charged fire extinguisher, one mounted next to the kitchen and one in the dining room. The facility has working fire sprinklers throughout the facility that were installed 3 months ago. LPA observed a First Aid kit and manual in the office locked and inaccessible to residents. LPA tested the working landline. There is an ADT alarm system throughout the facility that informs then when a door and which door is opened in the facility. All exits are marked and have facility sketches posted next to them. LPA observed emergency plan, emergency numbers and all required documents posted in the facility.

Infection Control There is a check- in station, at the office, when you enter the facility. There is a thermometer, hand sanitizer and logs for visitor, staff, and residents. LPA observed infection control signs posted throughout the facility. LPA observed sanitizing stations throughout the facility. LPA observed gloves mounted on the wall at the entrance of all bedrooms and bathrooms.

Medications and Files Medications will be stored in the locked office in a locked cabinet, inaccessible to residents. Files for staff and residents will be locked in a filing cabinet in the locked office and inaccessible to residents.

LPA reviewed the Liability Insurance, which is good till 1/20/24.

There are no advisory notes.

Componet III was reviewed and discussed.

LPA conducted an exit interview with the Administrator and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
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