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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601441
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:02:58 PM


Document Has Been Signed on 05/12/2022 01:02 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 HOME CAREFACILITY NUMBER:
075601441
ADMINISTRATOR:LINGBANAN, VICTORIAFACILITY TYPE:
740
ADDRESS:1621 THIRD AVENUETELEPHONE:
(925) 934-8827
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:22CENSUS: 16DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Renato Pundanera, CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
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On 05/12/2022 at 11:25 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver Renato Pundanera and explained the purpose of the visit. The facility’s fire clearance was approved for 22 residents. Administrator, Victoria Lingbanan arrived at 12:00pm.

LPA toured the facility with Renato Pundanera and Victoria Lingbanan including but not limited to 6 residents rooms, bathrooms, activity room, kitchen, common area patio and backyard. There are no bodies of water observed. LPA observe lighting in rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 77 downstairs and 75 upstairs degrees F. LPA observed lighting in rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

The following deficiencies was observed during the visit:

-At 12:01pm, LPA observed a mattress and bedframe.
-At 12:07pm, LPA observed 3 mattresses, 2 night stands and other stored items.

The following deficiencies were observed (see LIC 809D) and 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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/12/2022 01:02 PM - It Cannot Be Edited

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 HOME CARE
FACILITY NUMBER: 075601441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Administrator will remove 4 mattresses, 2 night stands and other items stored on patio and backyard into storage and will provide pictures to CCL no later than the POC date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2