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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603466
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:53:46 PM

Document Has Been Signed on 07/29/2024 01:53 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HARMONY HOMESFACILITY NUMBER:
198603466
ADMINISTRATOR/
DIRECTOR:		NEAL, ROBERTFACILITY TYPE:
735
ADDRESS:1147 EAST 88TH PLACETELEPHONE:
(213) 440-3617
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 4CENSUS: 3DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Robert Neal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to S1 (Staff #1) and was granted entrance to the facility . Administrator, Robert Neal arrived shortly thereafter. There are three (3) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through the South Central Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.


Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) ambulatory developmentally disabled clients between the ages of 18-59. It consists of three (3) shared client bedrooms, a living room, dining room, a kitchen, one (1) shared client bedroom, a shared client restroom whose hot water temperature measured at 102.2 Degrees F, a front and back patio area, and a laundry room.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Carbon Monoxide Detector was tested and operational. The facility has one (1) fully charged fire extinguisher that are kept in the kitchen of the facility and one (1) fully charged fire extinguisher in the dining room.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466
VISIT DATE: 07/29/2024
NARRATIVE
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· Cleaning supplies and toxic substances are inaccessible to clients in a locked cabinets underneath the sink in the kitchen.
· Water temperature reading during the tour of the facility was 102.2 Degrees F which does not measure between the required 105 - 120 degrees Fahrenheit which does not meet Title 22 Regulations. .
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) ambulatory developmentally disabled clients.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of three (3) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate is effective to 05/18/2025.


· Administrator does not have required HIV & TB training available in the facility which does not meet Title 22 Regulations. .
· Three (3) staff files were reviewed for criminal background clearance and training.
· S1 & S2 (Staff #2) Health Screening were not available in the facility which does not meet Title 22 Regulations. .
· S1's TB (Tuberculosis) Screening was not available in the facility which does not meet Title 22 Regulations. .
· Personnel records for 1st Aid/CPR training have been reviewed. .

Client Rights/Information:

· Facility provides a computer with internet access that all clients can use.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466
VISIT DATE: 07/29/2024
NARRATIVE
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Client Records/Incident Reports:

· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional, assessments, TB clearance, Individual Program Plan, personal rights, medication


records, and Personal and Incidental (P & I) money were reviewed.
· Medical Assessment with TB clearance for C1 (Client #1) and C2 (Client #2) were not available at the facility which does not meet TItle 22 Regulations. .
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Food Service:

· The kitchen was inspected and has regulation supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.


· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.



Incident Medical and Dental:

· Client’s individualized program plan from the regional center were reviewed.

· Staff training was reviewed. .

Disaster Preparedness, and Emergency Intervention:

· A posted Emergency Disaster Plan containing emergency evacuation information was observed.

· An emergency drill was last documented on 06/08/2024..



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SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466
VISIT DATE: 07/29/2024
NARRATIVE
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Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/29/2024 01:53 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/29/2024 at 01:22 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA, Daniel Konishi measured client’s shared restroom water temperature read at 102.2. degrees F, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee shall immediately adjust water temperature. Licensee to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Licensee will provide a copy of the log to the LPA once water temperature falls within Title 22 guidelines.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Administrator's file is missing training on HIV and TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Administrator will send a copy of the HIV and TB training certificate to the LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2024 01:53 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/29/2024 at 01:22 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,, LPA, Daniel Konishi observed in the personal records that the Health Screening for S1 and S2 were not available at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Administrator will send a copy of the Health Screening for S1 and S2 to the LPA by the POC due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA, Daniel Konishi observed that the Tuberculosis screening for S1 was not available at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Administrator will send a copy of the Tuberculosis screening for S1 to the LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2024 01:53 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/29/2024 at 01:22 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOMES
FACILITY NUMBER: 198603466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the LPA, Daniel Konishi observed that the medical assessment of C1 and C2 with the results of an examination for communicable Tuberculous and other contagious/infecious diseases was not available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Administrator will send a copy of the medical assessment with the results of an examination for communicable tuberculosis and other contagious/infectious diseases to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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