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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609988
Report Date: 05/04/2020
Date Signed: 06/12/2021 09:00:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HARMONY VILLA ALTADENA RCFEFACILITY NUMBER:
197609988
ADMINISTRATOR:NGUYEN, VIENFACILITY TYPE:
740
ADDRESS:669 W. CALAVERAS STTELEPHONE:
(626) 475-8330
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 6DATE:
05/04/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Vien NguyenTIME COMPLETED:
05:00 PM
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Licensing Program Analyst Manya Lefian conducted an announced pre-licensing visit telephonically/virtually due to the situation surrounding the Corona virus Disease 2019 (COVID-19) to implement mitigation measures with applicant/administrators Vien Nguyen. Component III was also conducted in conjunction with today's visit. This is a change of ownership application, therefore there were residents in care during todays visit. The fire clearance was granted on 4-14-2020 with the approval for five (5) non-ambulatory and one (1) bedridden residents.

The video call consisted of a tour of the physical plant, inside and outside of the facility.
LPA inspected facility for Fire Safety, Personal Accommodations and Services, medication procedures, and food service. First aid kit is complete, facility has adequate linen, water, perishable and non perishable food supplies. Facility has four bedrooms and three bathrooms. All bathrooms have the required grab bars and for showers and toilets. Hot water measured at 116 degrees F. Facility has working alarms on all exits. The facility smoke alarm system and carbon monoxide was tested and operable. All medications, chemicals and sharps are in a locked closet, cabinets, and drawers. Emergency exiting plan/sketch is posted in the living room. Emergency telephone numbers on the kitchen wall along with other required posters. There are no bodies of water on the premises. There is a working telephone as well.

A telephonic exit interview was conducted, and a hard copy was provided via email for signature.

Facility physical plant is in compliance with Title 22 regulations at this time. LPA will notify Centralized Application Unit as soon as verification for service of the fire extinguisher is provided by applicant.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Manya LefianTELEPHONE: (747) 230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2020
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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