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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320353
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:42:02 PM

Document Has Been Signed on 03/20/2025 02:42 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HARVARD HOPE HOUSEFACILITY NUMBER:
198320353
ADMINISTRATOR/
DIRECTOR:
COXSOM, AMBERFACILITY TYPE:
740
ADDRESS:4239 S. HARVARD BLVDTELEPHONE:
(323) 812-0788
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 6CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Amber Coxsom, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Amber Coxsom, Administrator and the purpose of the visit was discussed. Facility is licensed to 6 residents of which 4 may be non- ambulatory and 2 maybe bedridden residents age 60 and over . The facility has an approved hospice waiver for 6. Two residents are currently receiving hospice care services and none are receiving home health services at this time. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (4) resident bedrooms, (2) Full bathroom, living room, kitchen , dining area, laundry washer and dryer in kitchen and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 107.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Administrator Amber Coxsom

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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