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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610019
Report Date: 06/23/2020
Date Signed: 06/23/2020 03:54:56 PM

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 RESIDENTIAL CAREFACILITY NUMBER:
197610019
ADMINISTRATOR:BAZMIPOUR, PARHAMFACILITY TYPE:
740
ADDRESS:22235 WYANDOTTE STREETTELEPHONE:
(949) 338-4234
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY:6CENSUS: 0DATE:
06/23/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:BAZMIPOUR, PARHAMTIME COMPLETED:
04:00 PM
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Licensing Program Analyst Wendell Smith 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 Parham Bazmipour. Visit was conducted on 6/18/2020. Component three was conducted today 6/23/2020.

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 six bedrooms to which five are for residents and one for staff. Facility has three bathrooms of which two are for residents and one is for visitors/staff. All bathrooms have the required grab bars and for showers and toilets. Hot water measured at 115 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. LPA will notify Centralized Application Unit regarding the component three being complete along with the prelicensing visit being complete.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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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