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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601514
Report Date: 07/05/2024
Date Signed: 07/05/2024 12:38:04 PM

Document Has Been Signed on 07/05/2024 12:38 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HARVARD ADULT HOME CARE SERVICESFACILITY NUMBER:
198601514
ADMINISTRATOR/
DIRECTOR:		KIMBERLY TADYFACILITY TYPE:
735
ADDRESS:325 S. HARVARD BLVD.TELEPHONE:
(213) 380-2801
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY: 6CENSUS: 6DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:DSP Mardy LipatanTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with DSP worker Mardy Lipatan at approximately 10:11 AM and explained the reason for the visit. Acting Administrator Czarina Dorotan arrived shortly.There are currently six (6) clients in the facility. The facility is licensed to serve (6) developmentally disabled adults ages 18-59 years old of which (2) two can be non-ambulatory clients in room #3. Facility is operating within the approved capacity. The home consists of the living room, dining room, kitchen, (3) three client bedrooms, (1) one staff bedroom, office, (2) two bathrooms, detached 2 car garage/storage, and detached utility room/laundry room.

LPA Gutierrez conducted a tour of the facility, reviewed records, and interviewed 1 staff, and 1 client. The following were observed: Two (2) out of three (3) bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedroom #1 is missing two chairs and two night stands deficiency was cited. Bedrooms #1 also had hole from clients punching it on side of bed. Client beds have the required linen. Each bedroom has a smoke detector which were tested. There is a carbon monoxide detector located in the hallway and another in the living room area. The bathrooms were observed to be clean. The hot water was between 106.7 to 110.3 degrees which is within the required 105 - 120 degrees. There is a fire extinguisher in the living room and is fully charged. Sharps are locked in the kitchen and inaccessible to residents. Cleaning supplies and toxins are locked in outside cabinet and inaccessible to residents. First Aid kits were fully stocked with current manuals. There was a sufficient supply of 2 days perishable foods which included fruits and vegetables. Seven (7) days non-perishable foods were observed. The front and backyard are well maintained and there are no pools or large bodies of water Passageways and exits are free of obstruction. Backyard has a front and back patio area laundry machine, an office, a staff kitchen, and a detached garage which is a storage area for the facility.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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Document Has Been Signed on 07/18/2024 01:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/08/2024 04:01 PM


Created By: Christian Gutierrez On 07/05/2024 at 11:57 AM
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARVARD ADULT HOME CARE SERVICES
FACILITY NUMBER: 198601514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one (1) out of three (3) client's bedrooms. Bedroom #1 had hole in wall next to client's bed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Acting Administrator will call repair services and send receipt and picture as proof to LPA.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (2) out of six (6) client's did not have a chair or a nighstand in bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Acting Administrator will place two chairs and two nightstands in bedroom # 1 and email picture as proof to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HARVARD ADULT HOME CARE SERVICES
FACILITY NUMBER: 198601514
VISIT DATE: 07/05/2024
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Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in June of 2024. Infectious control plan was reviewed. One (1) staff was interviewed. Six (6) out of (6) client medications were reviewed. Medications are centrally stored in kitchen and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Czarina Dorotan.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
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