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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603240
Report Date: 10/20/2021
Date Signed: 10/20/2021 06:05:01 PM

Document Has Been Signed on 10/20/2021 06:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JMO HARMONYFACILITY NUMBER:
198603240
ADMINISTRATOR:SANCHEZ, VINCENTFACILITY TYPE:
735
ADDRESS:1716 LARK TREE WAYTELEPHONE:
(626) 474-2102
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 4DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Marcelo Canoza, DSP TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with the DSP Marcelo Canoza and Lolida Abzebe and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 04/10/21

The facility is a single story house located in residential neighborhood. The facility consists of four clients bedrooms, two bathrooms, living room, family room, dining area, second dining area, kitchen and an attached garage. Each client bedroom has one bed, one dresser, one chair, closet and an adequate lighting. All clients bedrooms have required linen which including the mattress pad. The hot water temperature in the bathroom #1 and #2 were measured between 94.2 and 101.3 degrees F which is not within Title 22 regulation. The food supply both perishable and non-perishable is sufficient. The backyard has shaded area and sitting area. The passageways, front, back and side areas are free from obstruction or free of hazards. The smoke detectors and carbon monoxide detectors are inter-connected and they are operational. At 3:10pm, LPA also observed the carpet in the family room and dining area is dirty and has a lot of black stains on it.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing by allowing two clients sitting in the dining table, disinfecting products are available in each room and facility is disinfected at least two times per day, restrooms have sufficient hand soap, paper towels, and signs, and PPE supplies are stored for more than 30 days.

Deficiencies are cited on the 809 D. Exit interview conducted and copies of the report and appeal right was provided to the DSP Marcelo Canoza
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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Document is an Amendment of Original Document on 11/04/2021 02:46 PM


Created By: Christine Wong On 10/20/2021 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JMO HARMONY
FACILITY NUMBER: 198603240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA checked the hot water temperature at bathroom#1 and #2 and they were measured between 94.2 and 101.3
POC Due Date: 10/21/2021
Plan of Correction
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The administrator will ensure the hot water temperature is measured between 105 and 120 degrees F. The administrator will adjust the hot water temperature immedidately and send the 10 days hot water temperature report to LPA via email.
Type A
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/10/2021
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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