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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005979
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:28:09 PM


Document Has Been Signed on 06/21/2022 04:28 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
306005979
ADMINISTRATOR:FERGUSON, KENNELLIEFACILITY TYPE:
740
ADDRESS:211 S ALICE WAYTELEPHONE:
6572204800
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Barbara HugoTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required 1 Year visit. LPA was greeted and granted entry into the facility by Staff Discoro Arceno and Barbara Hugo and explained the reason for the visit. LPA Martinez spoke to Administrator Kennellie Ferguson via telephone. Staff Hugo confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility. Staff present is cleared in Guardian but need to be associated to the facility.

LPA toured the facility with Staff Hugo. Facility has 4 residents in care of which one is receiving Hospice services during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. AC was on. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap, toilet paper and paper towels. Restrooms have hand washing signage posted. Facility screens all visitors to the facility and LPA observed the screening/sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. Facility has COVID precaution postings as well as all required department postings. Administrator Ferguson's has a conditional Administrator Certificate which expires on 10/07/2022. Facility has an approved Mitigation Plan on file. LPA observed the Emergency Disaster Plan posted. LPA observed adequate emergency food and water as well as the First Ad Kit which contained all required items. Smoke detectors/carbon monoxide detectors were operational at time of visit. Fire Extinguishers was last charged on 12/31/2020. LPA toured the outside grounds and observed ample shaded outside visitation area. Facility conducts activities such as puzzles, walking, and word search. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for COVID-19. LPA reviewed resident files and files have required documents including updated emergency contact information.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 306005979
VISIT DATE: 06/21/2022
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LPA consulted with AD via telephone on updated Emergency and Disaster Plan (LIC610D) and Infection Control Plan due 06/30/2022 PIN 22-13 ASC and PIN 22-18 ASC for a template for the plan.

No deficiencies noted during today's visit. An exit interview was conducted with AD Ferguson via telephone and a copy of this report along with LIC9102 was emailed during todays visit
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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