<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700283
Report Date: 12/23/2024
Date Signed: 12/23/2024 10:11:22 AM

Document Has Been Signed on 12/23/2024 10:11 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:
12/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Kirstin AtkinsTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hiratsuka conducted this unannounced case management visit in response to an incident report submitted by the facility.

Today, LPA obtained documents from two resident files.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1