197609988-9-9-2021-31-AS-NMAN-C76SQ3-20210924140403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609988
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:19:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210818083108

FACILITY NAME:	HARMONY VILLA ALTADENA RCFE		FACILITY NUMBER:	197609988
ADMINISTRATOR:	NGUYEN, VIEN		FACILITY TYPE:	740
ADDRESS:	669 W. CALAVERAS ST		TELEPHONE:	(626) 475-8330
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Tony Johnson, Staff		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Residents sustained pressure injuries while in care

Residents sustained unexplained bruising while in care

Facility has insects

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with Tony Johnson, Staff. The purpose of the visit was discussed.

It was reported that residents sustained pressure injuries while in care. To investigate this allegation, LPA spoke to Licensee Vien Nguyen on 08/26/2021 at 3:15pm. Interview revealed that Resident #1 (R1) had a pressure injury while at the hospital. R1 came to the facility with a pressure injury On 09/09/2021 at 2:46pm, LPA reviewed R1's physician report and appraisal. Documents confirmed that R1 has a history of skin condition breakdown and has been treated for pressure injuries in the past. Currently R1 does not have any pressure injuries. Documents reviewed revealed that other residents do not have any pressure injuries. Based on interviews and observation, there is not sufficient information to verify the allegation. Therefore the allegation is UNSUBSTANTIATED at this time.
See 9099-C for continuation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210818083108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARMONY VILLA ALTADENA RCFE	FACILITY NUMBER: 197609988
	VISIT DATE: 09/09/2021

NARRATIVE

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It was alleged that residents sustained unexplained bruising while in care. To investigate this allegation, LPA looked at all residents extremities on 09/09/2021 between 3:00pm and 3:20pm and did not observed any bruising on the hands, arms, or legs of any of the residents. On 08/26/2021 between 3:15 and 4:00pm, LPA spoke to Licensee and they stated that no abuse of any kind is tolerated at the facility. Based on observation and interviews, there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

It was reported that facility has insects. To investigate this allegation, LPA spoke to staff on 08/26/2021 between 3:15pm and 4:00pm. Interviews revealed that the facility is sprayed nightly to keep insects away. On 09/09/2021 between 3:30pm and 3:50pm, LPA did a physical plant tour of the facility and did not observe any insects. Based on interviews and observation, there is not sufficient information to verify this allegation. Therefore this allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

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