198603240-9-29-2023-28-AS-KRAZ-CW5VBE-20230929161721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603240
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:17:28 PM

Document Has Been Signed on 09/29/2023 04:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JMO HARMONY		FACILITY NUMBER:	198603240
ADMINISTRATOR:	SANCHEZ, VINCENT		FACILITY TYPE:	735
ADDRESS:	1716 LARK TREE WAY		TELEPHONE:	(626) 474-2102
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY: 4		CENSUS: 4	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Staff#1		TIME COMPLETED:	04:05 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/29/2023. LPA Ramirez was met by Staff#1 (S1) and explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 09:15 am and was led by S1. The facility is a single-story building located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, attached garage, front yard, backyard.

Front Yard: Well maintained and no hazards were observed.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink water temperature was measured at 116.1 degrees F.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 71 degrees F.

Linen Closet/Supply Closet/Laundry room: Contained plenty linens, towels, and hygiene products. All laundry detergents

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed all rooms to be clean. All client bedrooms are private. C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JMO HARMONY	FACILITY NUMBER: 198603240
	VISIT DATE: 09/29/2023

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Bathroom 1-2: Water temperature in client bathroom#1 was measured at 109.8 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Client bathroom #2, which is located in client bedroom#1, water temperature was measured at 11-.0 degrees F. LPA Ramirez observed grab bars in all showers and non slip mats in all bathroom showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in kitchen cabinet.

Backyard: No large bodies of water were observed.

Emergency Drills: Proof of last documented fire drill was on 09/21/23 at 8:00 am.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed five (5) staff files. LPA Ramirez observed a current Administrator’s certificate for Vincent Sanchez with an expiration date of 05/23/24.

Client Files: Four (4) client files were reviewed.

Infection Control Plan: LPA Ramirez reviewed current approve Infection Control Plan.

Exit interview was conducted. No deficiencies were observed. A copy of this report, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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