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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700283
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:24:28 AM

Document Has Been Signed on 01/14/2025 11:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HARMONY HOUSEFACILITY NUMBER:
312700283
ADMINISTRATOR/
DIRECTOR:		WAUTLET, BRANDONFACILITY TYPE:
735
ADDRESS:11080 B AVENUETELEPHONE:
(530) 886-3470
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 28CENSUS: 25DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Brandon WauletTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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LPA Hiratsuka conducted this unannounced case management visit. This is in response to learning the facility has not given copies of 30 day eviction notices issued to residents to Community Care Licensing Division. This is a violation of Title 22 regulations.

Deficiencies cited on the LIC 809-D, per Title 22 Regulations.

Exit interview conducted. A copy of the report has been issued. Failure to correct the deficiencies may result in Civil penalties being assessed. Appeal Rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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Document Has Been Signed on 01/14/2025 11:24 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 01/14/2025 at 10:51 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HARMONY HOUSE
FACILITY NUMBER: 312700283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
80068.5(e)

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Eviction Procedures. The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client.
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This was not met as evidenced by: Based on interview, it was learned the facility has not given copies of eviction notices to Community Care Licensing Division This poses a possible risk to the 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.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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