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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320116
Report Date: 11/20/2024
Date Signed: 11/22/2024 09:12:27 AM

Document Has Been Signed on 11/22/2024 09:12 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:HARVEY ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198320116
ADMINISTRATOR/
DIRECTOR:		SMYTH, JEWELFACILITY TYPE:
735
ADDRESS:1062 EAST 16TH STREETTELEPHONE:
(562) 883-3413
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 4CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Jewel Smyth, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On Monday, October 30, 2024 at 8:28am, LPA Zina Brown made an 2nd unannounced visit.
At 8:24 am Jewel Smyth, text LPA Brown to inform her she is currently at her facility in Victorville facility conducting meetings. LPA Zina Brown will attempt to conducted an unannounced visit at a later date.

On 11/20/2024 at 8:53am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Jewel Smyth (Administrator) and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory, adults ages 18 through 59 with developmental disabilities. Currently, there are zero (0) residents residing at the facility. The facility fees are a currently balance $0. The General Liability Policy #C1GP505444 is valid from 01/27/2024 to 01/27/2025 by Amguard Ins. Co coverage for 1,000,000/3,000,000.

The facility is a one story home located in a residential neighborhood. The property consists of the following: (2) client bedrooms, (1) common bathrooms, living room, kitchen with a washer and dryer, dining room, and an outdoor shaded area.

At LPA conducted a records review of (0) client records, (0) staff records, (0) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (0) Client Medication Administration Records as no residents currently resident at the facility and did not observed any discrepancies at the time of visit.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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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: HARVEY ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198320116
VISIT DATE: 11/20/2024
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At 9:20 am LPA and Jewel Smyth toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F at 124.5 F.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Jewel Smyth.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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