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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320116
Report Date: 11/12/2021
Date Signed: 11/13/2021 08:27:11 AM

Document Has Been Signed on 11/13/2021 08:27 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HARVEY ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320116
ADMINISTRATOR:SMYTH, JEWELFACILITY TYPE:
735
ADDRESS:1062 EAST 16TH STREETTELEPHONE:
(562) 883-3413
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 4CENSUS: 0DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Jewel SmythTIME COMPLETED:
10:00 AM
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On 11/12/2021, at 8:31 am, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Jewel Smyth, and explained the purpose of today’s visit. The facility is licensed to operate for four (4) Developmentally Disabled Adults, ages ranging from 18 to 59 years. Currently, there are no clients living in the facility.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: two (2) resident rooms, 1 bathroom, living room, dining area, kitchen, and covered front porch area with a bench seating for (4) people, and a back yard umbrella/ cover with table and four chairs and one barbecue.

LPA and Ms. Smyth toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 115 degrees Fahrenheit. A comfortable temperature of 75 degrees Fahrenheit was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguisher is charged, (3) smoke detectors/ carbon monoxide hardwired and operable.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HARVEY ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320116
VISIT DATE: 11/12/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Jewel Smyth, Administrator.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC809 (FAS) - (06/04)
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