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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700283
Report Date: 02/10/2022
Date Signed: 02/13/2023 09:33:12 AM

Document Has Been Signed on 02/13/2023 09:33 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HARMONY HOUSEFACILITY NUMBER:
312700283
ADMINISTRATOR:PORTILLO, ERIKAFACILITY TYPE:
735
ADDRESS:11080 B AVENUETELEPHONE:
(530) 886-3470
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 20CENSUS: 20DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brandon WautletTIME COMPLETED:
04:00 PM
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LPA Tryon arrived at the facility on 2/10/2022 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA had self-screened and used hand sanitizer. There are currently no positive Residents or staff. LPA wore an N-95 mask for the visit. The facility is doing screening of visitors at the front entrance including temperature check, screening of symptoms, requesting use of hand sanitizer, etc.

LPA toured the facility including common areas, dining room, resident bedrooms, bathrooms, hallways. There appears to be a good supply of PPE, soap, paper towels, cleaners, etc. There is a good supply of perishable, frozen and canned/dry goods food. The facility appears to be clean and generally in good repair.

LPA reviewed the infection control domain with the Administrator. Mitigation Plan is in place.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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