075601441-3-20-2025-15-AS-LAWN-DEXS9Q-20250320134107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601441
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:41:25 PM

Document Has Been Signed on 03/20/2025 01:41 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	HARMONY HOME CARE		FACILITY NUMBER:	075601441
ADMINISTRATOR/ DIRECTOR:	LINGBANAN, VICTORIA		FACILITY TYPE:	740
ADDRESS:	1621 THIRD AVENUE		TELEPHONE:	(925) 934-8827
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY: 22	TOTAL ENROLLED CHILDREN: 0	CENSUS: 14	DATE:	03/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Victoria Lingbanan, Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/20/2025 at 9:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Anabelle Mendoza and explained the purpose of the visit. Anabelle phoned Administrator/Licensee, Victoria "Vickie" Lingbanan to inform. Vickie arrived to the facility approximately 1 hour later. Facility’s fire clearance was approved for capacity twenty-two (22) residents in which all may be non-ambulatory. Hospice waiver approved for five (5) residents. Administrator certificate #6006625740 expires 11/25/2025. LPA toured the facility with Vickie including but not limited to five (5) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F downstairs and 75 degrees F upstairs. The hot water temperature in a sample of residents’ shared bathroom were measured at 102.4, 102, 103.3 degrees Fahrenheit. Administrator raised hot water temperature and now water is measuring at 115 degree Fahrenheit. 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. LIC809-C

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 03/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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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Document Has Been Signed on 03/20/2025 01:41 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOME CARE	FACILITY NUMBER: 075601441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(h)(1)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having an updated annual routine visit and documented medical assessment (LIC602-A) on file for R5, the last LIC602-A was dated 11/28/2018 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit an updated physician's report (LIC602-A) for R5 and submit to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 03/20/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 075601441
	VISIT DATE: 03/20/2025

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LIC809-C Continued (Page 2)

LPA reviewed seven (7) residents records. LPA reviewed four (4) staff records and 4 of 4 have current first aid training and associated to the facility.

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/03/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance
Current Administrator’s Certificate - Reviewed

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC809 (FAS) - (06/04)

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