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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601441
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:26:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211202105506
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: 15DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Victoria Lingbanan, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility is not in good repair.
INVESTIGATION FINDINGS:
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On 3/30/2023 at 10:10 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegation. Upon arrival, LPA was greeted by care staff, Luz Santos and explained the purpose of the visit. Administrator, Victoria Lingbanan later arrived at 10:30 AM.

During the course of the investigation, LPA obtained information, inspected food supply and elevator, reviewed records, collected documents, and conducted interviews with staff and residents. It was alleged facility is not in good repair. Based on information obtained, staff will kick the elevator door for elevator door to open, or for it to come down from second floor. On 3/30/2023, 4 of 4 staff confirmed that the elevator was down and it took a long period of time for elevator door to open. 2 of 5 residents stated that the elevator did not work for several times or there was a delay with the door.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211202105506

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: 15DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Victoria Lingbanan, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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2
3
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5
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9
Menus are not made available for residents.
Facility does not have sufficient funds to operate.
Food served by facility is not of the quality to meet the residents' needs.
INVESTIGATION FINDINGS:
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On 3/30/2023 at 10:10 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival, LPA met with care staff, Luz Santos and explained the purpose of the visit. Administrator, Victoria Lingbanan later arrived at 10:30 AM.

During the course of the investigation, LPA obtained information, inspected food supply and elevator, reviewed records, collected documents, and conducted interviews with staff and residents. It was alleged menus are not made available for residents. However, interview with 4 of 5 residents stated they never asked for a copy of the menu. On 3/30/2023, LPA observed weekly menus are maintained in a binder located in the kitchen.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20211202105506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/30/2023
NARRATIVE
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It was alleged facility does not have sufficient funds to operate. However, an interview with S1 and S2 on 3/30/23 revealed that the facility had an issue with original company the facility was contracted with. According to S1 and S2, the company ensured that the elevator was fixed, but facility was still experiencing the same issue. On December of 2022, facility switch with a new company and the elevator has been working since.

It was alleged food served by facility is not of the quality to meet the residents' needs. However, 5 of 5 residents stated they like the food and have no issues with the meals being served.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211202105506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
87303(a)
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87303(a) MAINTENANCE AND OPERATION
(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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DEFICIENCY CLEARED DURING VISIT. LPA obtained a copy of the invoice of the repair.
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Based on record review and interview, Licensee did not comply with the section cited above. 4 Staff and 2 residents confirmed there were issues with the elevator door not opening which poses a potential health and safety risk to residents in care.
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CCR
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20211202105506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/30/2023
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5