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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201516
Report Date: 05/19/2025
Date Signed: 05/19/2025 01:19:10 PM

Document Has Been Signed on 05/19/2025 01:19 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 CARE HOUSE LLCFACILITY NUMBER:
019201516
ADMINISTRATOR/
DIRECTOR:		NATH,NALINIFACILITY TYPE:
740
ADDRESS:565 SCHAFER ROADTELEPHONE:
(510) 701-3807
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 16CENSUS: 15DATE:
05/19/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nalini Nath, Licensee and Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 5/19/2025 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Pre-licensed and Comp III inspection. LPA met with administrator; Shirley Marshall currently holds a certificate (#6005261740) that expired on 06/26/2025. Licenses Nalini Nath was informed and arrived at a later time. The facility’s fire clearance was approved for sixteen (16) non-ambulatory residents.

LPA observed two residents in the dinning room.

With Shirley, LPA inspected the physical plant including but not limited to 4 bedrooms, 4 bathrooms, living room, kitchen/dining area, laundry, and the outdoor area. The facility is a 1-storey building that has 8 designated resident rooms. Other rooms observed were designated for dining, activity and laundry. There is also a room designated as an office. The rooms are provided with drawers, nightstand lamps, sidewall lamp by the bed, closets, drawers, chairs and beds with mattress, box springs, linens, bed sheets, comforters, mattress pads, pillows with pillowcases. There are 4 common toilet/bathroom at the facility. All resident bathrooms/toilets are equipped with grab bars. All exit doors are installed with alarm/auditory signals. Toiletry supplies, bedsheets, linens, towels, paper towels and toilet papers are available. First Aid kit was checked and observed to be complete with manual. Water temperature in the shared bathroom was tested at 115.2 degrees Fahrenheit. Facility had flashlights for emergencies. There were 3 lights in the hallway. There is a locked cabinet for medications in the kitchen. The facility had a written emergency disaster plan. Smoke detectors were interconnected. Currently, there is a working telephone located in the office. Administrator states 2 additional extension phones will be installed by 2/15/18. Varied activity supplies residents were observed.

There were non-perishable and perishable foods observed. Weekly menu is available. Dishes, glasses, and utensils are sufficient for the residents’ use. There was sufficient supply of warm blankets, hand towels, face towels and hand towels observed.

continuation on Lic 809C

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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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 CARE HOUSE LLC
FACILITY NUMBER: 019201516
VISIT DATE: 05/19/2025
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Multiple fire extinguishers were observed and showed purchased date on 2/23/2025. Several carbon monoxide detectors were observed and tested functional.

LPA observed the following deficiencies:

At around 10am, LPA observed trash bins on driveway is overflow with trashed and on the ground

At around 10:10am, LPA observed pizza slicer inside the dishwasher. Dishwasher used as storage.

At around 10:30am, LPA observed activities and resident drawer handle is broken and are missing

At around 10:33am, LPA observed shared bathroom are not clean

At around 10:35am, LPA observed broken title in the share bathroom

At around 10:40am, LPA observed in resident room contain a Corinz and cleaning product on top of the drawer (Shared room)

At around 10:45am, LPA observed Isopropyl Alcohol and dry shampoo in resident drawer (shared room)

At around 10:50am, LPA observed one nail polished inside the med chart, and multiple nail polishes left unlock on the shelve

At around 10:51am, LPA observed resident medication left unlocked in the drawer

At around 10:50am, LPA observed Lysol cleaning wipe outside in the back of the facility

At around 10:55am, LPA observed room 3 shared closet is being used as a storage

At around 10:55am, LPA observed room 7, 6, and 4 have a strong odor

At around 10:55am, LPA observed chemical left unlock in the drawer near the laundry room

At around 11:00am, LPA observed the wood on the patio have a whole and lift up

Prior to licensure, the following is to be faxed to CCL by 5/23/25 :

This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Comp III will be conduct after all POC is submit.

Exit interview conducted 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: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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