<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005979
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:58:19 PM


Document Has Been Signed on 01/08/2024 02:58 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:
(657) 220-4800
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 3DATE:
01/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Kennellie FergusonTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety visit in conjunction with complaint visit 22-AS-20240104163024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

At 2:00 PM, LPA toured the facility and observed the following: Facility appears clean and sanitary with ample food supply and operational appliances. There are three residents in care during today's visit. All residents appear clean and taken care of. Residents are relaxing in rooms or common areas during the visit. At 2:05 PM, LPA observed full rails on Resident 1's (R1) bed. R1 is not on hospice care. Facility has all required postings. LPA observed resident medications as well as toxins and cleaning supplies are secured. Facility has ample outdoor area with appropriate shade.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/08/2024 02:58 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2024
Section Cited
CCR
87608(a)(5)(B)

1
2
3
4
5
6
7
Based on the individual's preadmission appraisal.. Postural supports may be used under the following condition... Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care..This req is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to remove full bed rails and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on observation, Licensee failed to ensure full bed rails are not being utilized on any resident other than a hospice resident. R1 has full bed rails and is not on hospice. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2