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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700283
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:12:52 PM

Document Has Been Signed on 01/11/2024 04:12 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 19DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brandon WautletTIME COMPLETED:
04:30 PM
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On 1/11/2024 LPA Tryon visited the facility to conduct a required annual visit. LPA met with Administrator Brandon Wautlet.
LPA toured the facility with the Administrator including common areas, bedrooms, hallways, bathrooms, kitchen, food storage, dining room, outside recreation/smoking area/garden. LPA toured the dry food storage area, cooler and freezer. There is also a resident refrigerator in the dining room for resident snacks, etc. Food supplies appear to be adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Food appears of good quality and varied.
We also toured the medication room/office. Medications are centrally stored and locked.
The facility has a sprinkler/smoke detector/carbon monoxide detector system, which is checked as per schedule. Facility conducts emergency drills monthly.
The facility appears to be clean, well-furnished and spacious, There are recreation supplies available.

LPA reviewed the CARE Tool with the Administrator.

LPA reviewed 4 of 19 resident files. Files include required documentation.

The facility keeps staff training on a computer system. LPA reviewed the training with Administrator, staff appear to receive appropriate training.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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