195850340-6-16-2025-29-AS-QHUH-DHPQJC-20250616121232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850340
Report Date: 06/16/2025
Date Signed: 06/16/2025 12:12:51 PM

Document Has Been Signed on 06/16/2025 12:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HARMONY WELLNESS & CARE		FACILITY NUMBER:	195850340
ADMINISTRATOR/ DIRECTOR:	ZARGERY,ZOHRAB		FACILITY TYPE:	735
ADDRESS:	14632 COHASSET STREET		TELEPHONE:	(818) 640-3369
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 4		CENSUS: 2	DATE:	06/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:17 AM
MET WITH:	Zohrab Zargery - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced for a required one-year visit. LPA arrived at 9:17AM and met with facility Staff Champo Chilambwe, who then notified the Administrator. Administrator Zohrab Zargery arrived at 10:33AM. Entrance interview conducted. Beginning at 9:33AM, LPA and Staff conducted a tour of the physical plant areas to ensure clients’ health and safety and the facility is in compliance with Title 22 regulations. The facility is a Regional Center Level 6 one story residential home. The following was observed: KITCHEN: LPA observed an office area inside the kitchen with locked file cabinets near the refrigerator. Cabinet files contained client medications and facility files. Kitchen appliances and fixtures were clean and functional. The facility had a sufficient supply of perishable and non-perishable food. Food is prepared by the Staff and clients are allowed to prepare their own meals with supervision. Knives and other sharps are stored in a locked drawer. A first aid kit and one (1) fire extinguisher were observed and last serviced on 11/28/2024. COMMON AREAS: The Common Areas include the Family Room, Dining Room, and Laundry Room. The Laundry Room is attached to the kitchen with an operational washer/dryer. The facility’s cleaning supplies and laundry detergent were stored in nearby cabinets that remained locked. All furniture were clean and in good condition. There was sufficient space to accommodate both indoor and outdoor activities. There was a fireplace in the Family Room which was screened per regulation. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARMONY WELLNESS & CARE	FACILITY NUMBER: 195850340
	VISIT DATE: 06/16/2025

NARRATIVE

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Combination smoke detectors, carbon monoxide detectors, and fire door were tested at 9:59AM and were functional. Required postings were observed in the entryway hallway.

BEDROOMS: The facility had a total four (4) private bedrooms. Bedroom #4 is approved for non-Ambulatory clients and has a direct exit to the outside. All bedrooms were observed to contain appropriate furniture, bedding and linens. There were no visible hazards or inconsistencies observed. Extra linens were stored in all client Bedroom closets.

BATHROOMS: There are two (2) shared bathrooms located in the hallways. All bathrooms were observed to be clean and sanitary and supplied with appropriate paper and hygiene products with grab bars and non-slip mats. Water temperature was tested and measured between 109.2 degrees F and 111.4 degrees F. Bathrooms displayed hand washing signs.

SURROUNDING GROUNDS: The facility had a garage that remained locked and inaccessible to clients. The garage contained general storage, an extra refrigerator with extra food, and emergency food and water. The facility’s backyard provided a shaded area with furniture in good condition for client use. Exterior passageways were clean and clear of any obstructions. There are two (2) side gates with a self-latching mechanism for persons to exit the backyard in emergencies, one (1) side gate was locked.

RECORD REVIEW: LPA reviewed two (2) client file records at 10:12AM. Client records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Client files reviewed contained all required documents. LPA reviewed four (4) staff records during today's visit. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit.

Report Continued on LIC 809-D

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARMONY WELLNESS & CARE	FACILITY NUMBER: 195850340
	VISIT DATE: 06/16/2025

NARRATIVE

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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and reviewed annually. The facility conducts emergency drills as required, with the last drill documented on 05/26/2025.

MEDICATION REVIEW: LPA reviewed one (1) client’s medication at 11:12AM. The client’s medication was stored and administered in compliance with regulation.

No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and issued.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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