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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005979
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:55:28 AM


Document Has Been Signed on 08/28/2024 09:55 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
ORANGE COUNTY RO, 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: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Veahlou DaeltoTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA met with Caregivers Clark John Culala and Gerald Alarcon and purpose of visit was shared. Assistant Administrator (AD) Veahlou Daelto arrived shortly after. AD Daelto informed LPA Martinez that Kennellie Ferguson is the Licensee/Administrator but facility is going through a change of ownership.

LPA Martinez, along with staff toured the inside and outside of the facility. Facility currently has five residents in care of which two are receiving Hospice services. LPA observed residents in their perspective rooms either asleep or watching TV. All residents were observed clean and well taken care of. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Backyard has a covered patio for outdoor activities and sufficient seating for residents and visitors. Bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean and have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted. Stove burners, dishwasher, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the residents. Medication was observed locked in a kitchen cabinet. Medications reviewed appear to have been dispensed accurately.
LPA observed the Emergency Disaster Plan posted. LPA reviewed 5 resident files and 2 staff files; and interviewed residents and staff. LPA confirmed Administrator's certificate expires on 10/06/2024.
Based on observations made during today's visit, no deficiencies are being cited. An exit interview was conducted with Assistant Administrator and a copy of this report was sent to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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