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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200702
Report Date: 08/10/2026
Date Signed: 08/10/2026 01:32:10 PM

Document Has Been Signed on 08/10/2026 01:32 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HARMONY HOMES LLCFACILITY NUMBER:
019200702
ADMINISTRATOR/
DIRECTOR:		NATH, NALINIFACILITY TYPE:
740
ADDRESS:3263 SANTA CLARA COURTTELEPHONE:
(510) 400-9373
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
08/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Annabelle Marinas, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 08/10/2026 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPA met with Direct Care Staff, Annabelle Marinas, and explained the purpose of the visit. The Administrator was not available for today’s visit and authorized staff to sign the report.

LPA toured the facility inside and out, including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. The facility consists of 5 bedrooms, of which 4 are occupied by residents, and 1 is occupied by staff. No bodies of water were observed. LPA observed that lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents' shared bathroom was measured at 111 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during the visit. The fire extinguisher was last serviced on 3/11/2026. Emergency Disaster Plan was last posted on 05/26/2026. First aid kit was observed to be complete. Emergency disaster drill, including but not limited to fire, earthquake, and power failure, was last conducted on 07/20/2026.

At 9:30 AM, LPA reviewed 4 residents' records. At 10:05 PM, LPA reviewed 4 of 4 residents’ medications. At 11:00 AM, LPA reviewed 4 staff records, and 4 of 4 have current first aid training and are associated with the facility.

Continue to LIC809-C...

Bennett Fong
Kelly Nguyen
DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702
VISIT DATE: 08/10/2026
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Continue to LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:05 AM, LPA conducted a file review and observed that R1, R2, R3, and R4 medications were not as prescribed by the doctor's order.

At 12:00 PM, LPA observed medication left unlocked inside the closet and in RM 1, RM 3, and RM 4 drawers/closets (ointment, Desonide, Gentian Violet topical solution 1%)

At 12:10 PM, LPA observed chemicals left unlocked inside RM 1, RM 3, and RM 4 (isopropyl Alcohol, Power Clean, Medline Sterile Saline Wound Spray, Oatey Clear Cement, etc. accessible to residents in care.

At 12:30 PM, LPA observed a drawer blocking the exit door in Bedroom #1.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

A civil penalty is being assessed as of today in the amount of $500.

Exit interview conducted. LIC 421FC, Appeal Rights and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/10/2026 01:32 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/10/2026 at 12:44 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 by chemicals left unlocked inside RM 1, RM 3, and RM 4 (isopropyl Alcohol, Power Clean, Medline Sterile Saline Wound Spray, Oatey Clear Cement, etc. accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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ADM will remove all chemical from RM1, RM3, and RM4 and submit proof to CCLD by POC date. The Administrator agrees to self-certify the regulation with staff and send proof to CCLD by POC date 8/19/26.
A civil penaty is being access on today date in the amount of $250.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having medication left unlocked inside the closet and in RM 1, RM 3, and RM 4 drawers/closets (ointment, Desonide, Gentian Violet topical solution 1%) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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ADM will lcoked up all medications from RM1, and RM3 and submit proof to CCLD by POC date. The Administrator agrees to self-certify the regulation with staff and send proof to CCLD by POC date 8/19/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2026 01:32 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/10/2026 at 12:44 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by having a drawer blocking the exit door in Bedroom #1. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
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Staff removed the drawer during the visit. The Administrator agrees to self-certify the regulation with staff and send proof to CCLD by POC date.
A civil penaty is being access on today date in the amount of $250.
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having R1, R2, R3, and R4 medications were not as prescribed by the doctor's order. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
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The administrator agrees to ensure that all residents’ medications are administered in accordance with the physician’s orders. The Administrator will conduct an in-service training with all medication staff regarding medication administration, including verifying the medication name, dosage, frequency, and physician’s orders prior to administration. The Administrator will conduct medication record reviews and medication audits to ensure compliance and will address any discrepancies immediately. Documentation of the training and medication audits will be maintained at the facility and made available to CCLD upon request.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2026


LIC809 (FAS) - (06/04)
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