<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005979
Report Date:
01/16/2024
Date Signed:
01/16/2024 09:57:55 AM
Document Has Been Signed on
01/16/2024 09:57 AM
- 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 CARE
FACILITY NUMBER:
306005979
ADMINISTRATOR:
FERGUSON, KENNELLIE
FACILITY TYPE:
740
ADDRESS:
211 S ALICE WAY
TELEPHONE:
(657) 220-4800
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92806
CAPACITY:
6
CENSUS:
2
DATE:
01/16/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
09:22 AM
MET WITH:
Julian Briones
TIME COMPLETED:
10:16 AM
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 (LPAs) Kimberly Lyman conducted an unannounced visit for the purpose of a Plan of Correction (POC) visit based on deficiencies cited on 01/08/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.
*Deficiency cited under Title 22 Regulation 87608(a)(5)(B) pertaining to Postural Supports has been cleared. Full bed rails have been removed. Licensee has complied with the terms of the POC.
Licensee received an advisory note on 01/08/2024. LPA observed the following:
Sharps are secured during today's visit.
All half rails have been moved to the top of the beds.
There is ample emergency water and canned goods.
Licensee has been advised to maintain all items in compliance with Title 22 regulations.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
01/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/16/2024
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
1