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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700283
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:28:25 PM

Document Has Been Signed on 09/30/2024 02:28 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/
DIRECTOR:		WAUTLET, BRANDONFACILITY TYPE:
735
ADDRESS:11080 B AVENUETELEPHONE:
(530) 886-3470
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 20CENSUS: DATE:
09/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 9/30/2024 LPA Tryon made a brief visit to the facility to Amend a Complaint document originally dated 9/4/2024. Complaint number is 59-AS-20240118120524. Document was made confidential in error; document should have been Public. Change and amended document completed on this date, signature obtained.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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