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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804284
Report Date: 05/08/2026
Date Signed: 05/08/2026 01:13:13 PM

Document Has Been Signed on 05/08/2026 01:13 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HARMONY ONE CARE HOMEFACILITY NUMBER:
236804284
ADMINISTRATOR/
DIRECTOR:		WONG, STANLEYFACILITY TYPE:
740
ADDRESS:512 CANYON VIEW CTTELEPHONE:
(707) 380-7494
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 7CENSUS: 7DATE:
05/08/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Stanely WongTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit to follow up on deficiencies observed during the annual inspection on 03/09/2026. LPA met with Licensee Stanley Wong. LPA reviewed the previous areas of concern and observed the items remain in compliance. During this inspection, LPA observed two individuals living in a staff room. LPA was informed they have been present and working the morning shift for approximately one month. Neither individual were listed on the facilities background check roster. An immediate civil penalty is being issued in the amount of $100 per day for 5 days for each individual, totalling $1,000. Licensee informed LPA that they have not received their required 40 hours of initial training.
During this visit LPA observed residents sleeping in the living room with the blinds closed and soft music playing. LPA discussed regulation regarding planned activities with Licensee.

LPA spoke with Licensee about the Departments Technical Support Program. Licensee expressed interest in receiving assistance with Administrator responsibilities, Staff and Resident record keeping.

LPA provided copies of Regulations 87355, Criminal Record Clearance, 87412, Personnel Records, Direct Care staff training requirement documentation and 87219, Planned Activities.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Stanley Wong and appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/08/2026 01:13 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 05/08/2026 at 12:14 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2026
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance- 87355(e)(1)- All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee agrees to ensure all staff receive a criminal records clearance prior to working or residing at the facility. Licensee shall submit evidence of a cleared background clearance and association to the facility by 05/09/2026.
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This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, 2 staff were living in a staff room and did not have a background clearance or associated to the building. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.
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Type B
05/29/2026
Section Cited
HSC1569.625(b)(1)

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1569.625 Staff training; legislative findings; contents: (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly...This training shall consist of 40 hours of training. This requirement is not met as evidenced by:
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Licensee agrees that all new staff shall receive the required training hours prior to working on their own with residents. Licensee shall submit evidence of completed staff training for S1 and S2 by 05/29/2026.
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 Based on interviews conducted, Licensee did not provide new staff the required number of training hours. This poses a potential Health, Safety or Personal Rights risk to residents in care.
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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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2026


LIC809 (FAS) - (06/04)
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