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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601377
Report Date: 01/30/2025
Date Signed: 01/31/2025 08:18:35 AM

Document Has Been Signed on 01/31/2025 08:18 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:EXCELSIOR HOUSEFACILITY NUMBER:
191601377
ADMINISTRATOR/
DIRECTOR:		JAVANFARD, ELANFACILITY TYPE:
772
ADDRESS:1007 SOUTH MYRTLE AVENUETELEPHONE:
(310) 412-4191
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 14CENSUS: 10DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:DIRECTOR CASSANDRA WINTERSTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 01/30/2025 Community Care Licensing Division (CCLD) staff conducted an unannounced required 1-year annual visit to Excelsior House Facility with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, CCLD staff conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. CCLD staff met with Director Cassandra Winters. CCLD staff explained the purpose of today's Annual Inspection. CCLD staff verified that the facility has an approved mitigation plan report and infection control report. The facility's annual fees are current. The facility currently has ten (10) ambulatory clients in placement.

The facility is a two-story building located in a business/residential neighborhood. Director Winters and CCLD staff made a complete tour of the facility which consisted of upstairs and downstairs. The facilities’ last fire drill was conducted on 01/14/2025. CCLD staff noted the Administrator Elan Javanfard Certification # 7016559735 expiration date of 7/9/2026 was valid at time of inspection. The facility does not handle clients’ money/cash resources and no surety bond is needed. Commercial General Liability Policy #202402240 policy period from 04/01/2024 to 04/01/2025 underwritten by Proassurance Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Director Winters to email CCLD staff a full copy of the commercial insurance policy including all endorsements no later than 02/10/2025. All the required documents are posted in the facility in a clearly visible area
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: EXCELSIOR HOUSE
FACILITY NUMBER: 191601377
VISIT DATE: 01/30/2025
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The downstairs consists of the main office, living room/common area, dining room/group meeting area, kitchen, Administrator's office, Counselor's office, Therapist's office, medication room, arts, and craft closet, two (2) all-gender bathrooms, utility closet emergency supplies room, and numerous of storage closets are downstairs. The upstairs has seven (7) bedrooms, two (2) all-gender bathrooms, one (1) all-gender staff restroom, laundry room, staff lounge, Doctor's office, Director's office, and numerous storage closets. Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, a working telephone, smoke, and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the medication room, no firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. The outside includes a gated front parking lot, a backyard-covered patio/shaded areas, and indoor/outdoor activity areas.

Due to time constraints and insufficient information available currently, the above allegations need further investigation. No deficiencies were cited. An exit interview was conducted, and a copy of the annual report was given to Director Winters.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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