198320353-1-31-2024-11-AS-EGOZ-CZZRZY-20240131122842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320353
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:28:54 PM

Document Has Been Signed on 01/31/2024 12:28 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:	HARVARD HOPE HOUSE		FACILITY NUMBER:	198320353
ADMINISTRATOR:	COXSOM, AMBER		FACILITY TYPE:	740
ADDRESS:	4239 S. HARVARD BLVD		TELEPHONE:	(323) 812-0788
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Amber Coxsom		TIME COMPLETED:	12:30 PM

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On 01/31/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit to the above facility. LPA met with Marcia Williams Coxsom and the purpose of the visit was discussed. LPA was granted access to the facility. Administrator Amber Coxom arrived at the facility shortly after and joined LPA for the visit. Facility is approved for six (6) residents of which four (4) may be non-ambulatory and two (2) may be bedridden. Facility has an approved hospice waiver for six (6) hospice residents.

The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) bedrooms, two (2) bathrooms, kitchen, laundry area, living room, dining room, and an office/check in area. In the back yard there is a seating area with tables, chairs, and an umbrella for shade. There is also an additional building on the property with its own address and is not part of the facility.

LPA and Amber Coxsom, Director toured the inside and outside grounds of the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The water temperature measured between 105.0 F and 120.0 F in both bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. A comfortable temperature was maintained in the facility.

The kitchen was checked and observed to be within Title 22 regulations. Sufficient perishable and non-perishable food supply was maintained adequately. All sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents.

Continued on LIC-809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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: HARVARD HOPE HOUSE	FACILITY NUMBER: 198320353
	VISIT DATE: 01/31/2024

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A review of Medication Administration Records was maintained in order and accurate. The facility has a landline telephone on-site in working condition. Medications were centrally stored and properly locked. Smoke detectors and carbon monoxide detectors were operational and working properly. LPA observed two (2) fully charged fire extinguishers. LPA observed a stocked First Aid kit along with manual locked and inaccessible to residents. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Report and Appeal Rights was provided to Amber Coxsom, Director.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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