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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609988
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:09:05 PM


Document Has Been Signed on 08/02/2022 04:09 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, 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: 0DATE:
08/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Vinh Vong, StaffTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced case management visit to the facility to ensure that there are no residents in care. LPA met with Vinh Vong, staff. The purpose of the visit was discussed with the administrator.

At 12:40pm, LPA Valenzuela began a physical plant tour of the facility. LPA inspected the four (04) rooms were residents in care resided. All four (04) rooms were vacant. There were no residents in any of the rooms. LPA looked inside the closets and checked all drawers and saw no personal belongings or clothes inside.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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