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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604054
Report Date: 10/27/2021
Date Signed: 10/28/2021 10:51:59 AM

Document Has Been Signed on 10/28/2021 10:51 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HARMONY HOMEFACILITY NUMBER:
374604054
ADMINISTRATOR:ESCOBAR, CONNIEFACILITY TYPE:
735
ADDRESS:415 S. F STREETTELEPHONE:
(760) 455-7967
CITY:IMPERIALSTATE: CAZIP CODE:
92251
CAPACITY: 4CENSUS: 4DATE:
10/27/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Connie Escobar TIME COMPLETED:
12:47 PM
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Licensing Program Analyst (LPA), Kristina Ryan, Imperial County Public Health Nursing Manager, Steven Solis and Community Health Nurse, Corina De Leon conducted an on-site visit. The team identified themselves, and discussed the purpose of the visit with Administrator, Connie Escobar.

The Department conducted the on-site visit to introduce the Imperial County Public Health Team to Ms. Escobar and to provide consultation for mitigation strategies regarding COVID-19. During today's visit, the team interviewed the administrator and conducted a walk-through of the facility. A debriefing was conducted with the administrator at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Ms. Escobar, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the administrator via electronic mail. An electronic receipt confirms receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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