019200702-8-17-2022-15-AS-CLIN-CHDTSJ-20220817145914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200702
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:59:45 PM

Document Has Been Signed on 08/17/2022 02:59 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 HOMES LLC		FACILITY NUMBER:	019200702
ADMINISTRATOR:	NATH, NALINI		FACILITY TYPE:	740
ADDRESS:	3263 SANTA CLARA COURT		TELEPHONE:	(510) 701-3807
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Annabelle Marinas, Staff		TIME COMPLETED:	03:15 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 8/17/2022 starting at 9:25 a.m., Licensing Program Analysts (LPAs) C. Lin and M. Malik arrived unannounced to conduct Infection Control Inspection. LPAs met with staff Annabelle Marinas, Administrator was not available during visit and authorized staff to sign on the report through phone. LPAs disclosed the purpose of the visit. During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors. THE FOLLOWING DEFICIENCIES WERE OBSERVED: · Approximately at 9:25 a.m., LPAs observed the front gate of accessing to facility was not opening properly, it's required extra strength to slid open. LPAs also observed that the side wood gate from backyard to outside was disrepair. the post of holding the wood door was losing and moving around. Administrator and staff admitted it and agreed to fix it ASAP. · Approximately at 9:30 a.m., LPAs observed S1 started working in facility on 7/1/2022 but has not been associated with facility. Administrator admitted that she has not completed transferring S1 to be associated. · Approximately at 9:35 a.m., LPAs observed unlocked laundry detergent powder in a open plastic container under the sink. Staff removed it and locked it up during visit. LPAs also observed unlocked paint and tools in the backyard Continue LIC809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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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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 HOMES LLC	FACILITY NUMBER: 019200702
	VISIT DATE: 08/17/2022

NARRATIVE

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· Approximately at 9:45 a.m, LPAs observed unlocked over-the-counter medications in a cabinet under the counter top facing to the dining table in the dining room. Staff admitted these medications belonged to staff instead of residents. Administrator instructed staff to lock them up through the phone.
· Approximately at 10:20 a.m, LPAs observed there has no fresh vegetable and fruits except 3 bananas and 2 oranges in facility. Caned peach was observed to be served to residents at lunch. Administrator agreed to replenish food today.
· Approximately at 10:30 a.m, LPAs observed the smoke detector was disfunctional. Administrator agreed to have it fix today.

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 staff. LIC809D, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2022 02:59 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 HOMES LLC	FACILITY NUMBER: 019200702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed unlocked over-the-counter medication in a cabinet in the kitchen; unlocked cleaning supply under the kitchen sink, and paint and tools in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2022
	Plan of Correction
1 2 3 4	Deficiency Cleared. Staff locked up all items during visit.

Type A

Section Cited

CCR

87355(b)

87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above, S1 started working for facility on 7/1/2022 but has not been associated with facility, and there was no criminal record is found in facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2022
	Plan of Correction
1 2 3 4	Administrator agreed to associate staff with facility and submit proof to CCL by the POC due date. Due to lack of staffing, S1 is allowed to work with a cleared staff for 24 hours only. Administrator will arrange other staff if S1 is not cleared by POC due date.

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	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2022 02:59 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 HOMES LLC	FACILITY NUMBER: 019200702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(a)

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed facility has no fresh vegetable and fruits except 3 bananas and 2 oranges which poses immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2022
	Plan of Correction
1 2 3 4	Administrator agreed to replenish food today, and submit copy of receipts and photos to CCL by the 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

Page: 4 of 11

Document Has Been Signed on 08/17/2022 02:59 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 HOMES LLC	FACILITY NUMBER: 019200702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed that the front gate and side wood gate were not opening properly which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2022
	Plan of Correction
1 2 3 4	Administrator agreed to have all doors fix and submit photos to CCL by the 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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