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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320121
Report Date: 02/21/2025
Date Signed: 02/21/2025 12:56:19 PM

Document Has Been Signed on 02/21/2025 12:56 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:HARLAN HOUSEFACILITY NUMBER:
198320121
ADMINISTRATOR/
DIRECTOR:		LEVIAS, KARLTONFACILITY TYPE:
735
ADDRESS:19207 HARLAN AVENUETELEPHONE:
(424) 224-1525
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:14 AM
MET WITH:Administrator Ronald DavisTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 02/21/25 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Ronald Davis as the purpose of today’s visit was explained. The facility is licensed to serve 4 Developmentally Disabled clients (age 18-59); ambulatory only. Current census is 4 ambulatory clients. The clients are South Central Los Angeles Regional Center clients. Facility fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, indoor and outdoor activity area, laundry room and an attached garage. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 4 client records, 4 medication administration records, and 4 P&I ledgers, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 09/10/24, fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

Exit interview conducted, appeal rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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Document Has Been Signed on 02/21/2025 12:56 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 02/21/2025 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARLAN HOUSE
FACILITY NUMBER: 198320121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(2)
Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above as LPA observed the restroom to have a hole that measures approx 6 inches behind bathroom door, there is also a hole approx. 4 inches in the living room area
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee to repair holes and send LPA proof of repair by POC due date.
Lizeth.villegas@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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