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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200702
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:53:56 PM

Document Has Been Signed on 07/09/2024 03:53 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 HOMES LLCFACILITY NUMBER:
019200702
ADMINISTRATOR/
DIRECTOR:		NATH, NALINIFACILITY TYPE:
740
ADDRESS:3263 SANTA CLARA COURTTELEPHONE:
(510) 400-9373
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Nalini Nath, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 07/9/2024 at 10:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA was greeted by care staff, Annabelle Marimas. Care staff informed Administrator (AD) Nalini Nath. LPA spoke with AD and explained the purpose of the visit. LPA conducted the inspection process, later AD arrived.

LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

Fire drill was conducted on 6/7/2024. Fire extinguisher last check on 2/15/2024. Emergency plan was last posted on 7/9/2024. Facility has a current liability insurance from 2024-2025.

LPA reviewed 2 staff record and two out of 2 have TB on file, also associated to the facility. LPA reviewed five resident files.

Continue LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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 5
Document Has Been Signed on 07/09/2024 03:53 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 07/09/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 by having mold in the jam jar and mold on the cantalope, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator remove the mold items during visit. Deficiency cleared
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having medication left unlock in, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator locked the medication drawer during medication. Deficiency cleared
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 Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/09/2024 03:53 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 07/09/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 by having mold/ rust in the resident bathroom wall, 4 window screen rip, residents drawers broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator agree to fix and repair and send photo of proof to CCLD by POC date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by having wheel chair and drawer blocking the exit doors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator remove the wheel chair and drawer during inspection. Deficiency cleared
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 Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/09/2024 03:53 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 07/09/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY HOMES LLC
FACILITY NUMBER: 019200702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having 4 out of 5 resident PRN without a doctor order, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator agree to obtain PRN from doctor, and submit documentation to CCLD by the POC date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having lable/ date on the PRN, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator agree to get residents PRN lable by the doctor, and send documentation to CCLD by POC.
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 Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 HOMES LLC
FACILITY NUMBER: 019200702
VISIT DATE: 07/09/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· Approximately at 10:30 a.m., LPA observed four window screen rips.
· Approximately at 10:50 a.m., LPA observed resident bathroom wall have mold/ rust.
· Approximately at 11:00 a.m., LPA observed resident drawer are not in working condition.
· Approximately at 11:10 a.m., LPA observed wheelchair and drawer are blocking the exit way.
· Approximately at 11:30 a.m., LPA observed unlock medication in the drawer.
· Approximately at 11:45 a.m., LPA observed mold in the jam jar and cantaloupe in the cabinet.
· Approximately at 12:10 p.m., LPA conducted file review 4 out of 5 residents PRN without doctor order.



The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with administrator. LIC809D, Appeal Rights and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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