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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920253
Report Date: 07/29/2026
Date Signed: 07/30/2026 02:02:04 PM

Document Has Been Signed on 07/30/2026 02:02 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 HAVEN CARE HOMEFACILITY NUMBER:
345920253
ADMINISTRATOR/
DIRECTOR:		CRISTINA IVASCUFACILITY TYPE:
740
ADDRESS:7974 COBB STTELEPHONE:
(916) 699-0464
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
07/29/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Michel Nguyen, caregiver TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report to the Department. LPA met with Michel Nguyen, caregiver, and stated the reason for today's inspection. LPA observed (3) residents in the common area and (3) residents resting in their rooms.

LPA was advised of a new administrator at the start of the inspection spoke to the Administrator, Manav Soha, by phone, who indicated he started his position on June 1, 2026. The administrator confirmed he has a current RCFE Administrator certificate and there is a pending application for a new license that was submitted on/around the first part of June, 2026. LPA discussed how a 60-day written notice must be issued to the responsible persons/residents prior to the change in ownership. LPA stated that the change in administrator should have been reported within (30) days. LPA obtained an updated phone contact phone and email address for the new Administrator.

Also discussed was the recent hospitalization of resident (R1) on July 15, 2026. The incident report notes that (R1) was sent out to the emergency room due to appearing shaky and not fully responding to staff. LPA confirmed this information with the Administrator and the caregiver that (R1) that (R1) returned to the community later the same day and has completed their (5-day) antibiotic course of Amoxicillin 500 mg, 3 times daily . LPA observed (R1) to be resting in their room during the inspection. The Administrator stated that (R1) returned to the community, under hospice, per the family's request. LPA and caregiver toured the interior of the facility and observed all residents to be resting and the facility was clean, in good repair and odor free.
Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued for not reporting the administrator change within (30) days.
Exit interview with caregiver, who was authorized to sign today's report. Copy of report/appeal rights given.
Lauren Crocker
Sabrina Calzada
DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/30/2026 02:02 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 07/29/2026 at 02:58 PM
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 HAVEN CARE HOME
FACILITY NUMBER: 345920253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2026
Section Cited
CCR
87211(g)(1-3)

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87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
(1) Name and residence and mailing addresses of the new administrator.
(2) Date he/she assumed his/her position.
(3) Description of his/her background and qualifications, including documentation of required education and administrator certification. This requirement is not met as evidenced by:
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Licensee/Administrator agree to submit the specific documentation, per Regulation 87211, to the Department by August 12, 2026.


Documents can be emailed to LPA or faxed to the Regional Office.
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Based on interview with the new Administrator, the Licensee did not notify the Department, within (30) days, of the change in Administrator on June 1, 2026, which posed a potential health and safety risk to 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.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Sabrina Calzada
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2026


LIC809 (FAS) - (06/04)
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