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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320121
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:51:47 PM

Document Has Been Signed on 02/22/2023 02:51 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:HARLAN HOUSEFACILITY NUMBER:
198320121
ADMINISTRATOR:LEVIAS, KARLTONFACILITY TYPE:
735
ADDRESS:19207 HARLAN AVENUETELEPHONE:
(424) 224-1525
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Ronald Davis, Co-AdministratorTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Ronald Davis, Co-Administrator, DSP Lashun Holley, DSP and Karlton Levias Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (age 18-59) ambulatory only.

There are currently four (4) South Central Regional Center clients in placement. All (4) clients are ambulatory. The facility is a one-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room located in the attached garage. All clients were observed and at the facility.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were 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 regulations and were clean and operational. The water temperature was measured. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

See LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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: HARLAN HOUSE
FACILITY NUMBER: 198320121
VISIT DATE: 02/22/2023
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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 ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Administrator, Karlton Levias.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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