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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610019
Report Date:
06/29/2021
Date Signed:
06/29/2021 03:43:05 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 CARE
FACILITY NUMBER:
197610019
ADMINISTRATOR:
BAZMIPOUR, PARHAM
FACILITY TYPE:
740
ADDRESS:
22235 WYANDOTTE STREET
TELEPHONE:
(949) 338-4234
CITY:
CANOGA PARK
STATE:
CA
ZIP CODE:
91303
CAPACITY:
6
CENSUS:
3
DATE:
06/29/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
Lady Fatima Magat
TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual visit. LPA met with facility staff and explained the reason for the visit. Administrator was notified of the visit.
Upon entry LPA conducted a physical plant tour. Facility has six bedrooms and three bathrooms. Five bedrooms are for residents while one is for staff. LPA observed all resident bedrooms to be appropriately furnished. There are three bathrooms which all had grab bars and non skid material. LPA observed all common areas to be appropriately furnished. All the required postings were posted and in plain view. LPA observed the smoke detector and carbon monoxide detector to be working properly. LPA checked the kitchen area for the ability to store and prepare food. LPA observed a sufficient amount of perishable and non perishable food. All knives and sharp objects were locked away and inaccessible. Facility is following all the infection procedure protocols suggested by the Department. Facility currently has three residents on hospice. Medications were observed to be locked away and inaccessible. No deficiencies cited. Exit Interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/29/2021
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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