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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601441
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:40:17 AM


Document Has Been Signed on 04/25/2024 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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:
04/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Victoria Lingbanan, LicenseeTIME COMPLETED:
12:00 PM
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On 04/25/2024 at 10:45 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Caregiver, Dorris, and informed the reason for visit. Dorris phoned the Licensee/Administrator, Victoria Lingbanan to inform. Victoria arrived around 11:15 AM.

On 03/26/2024, LPA conducted an Annual visit in which deficiencies were cited. The POC due date was 04/16/2024. Administrator failed to submit the POC by the due date and this is why LPA came to make a POC visit.

Facility has the following deficiencies that was not cleared:
  • 87303(a) $100.00 x 9 Days = $900.00

Civil Penalties in the total amount of $900.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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