374604054-10-17-2023-08-AS-RARZ-CWPUDK-20231017152940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604054
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:29:45 PM

Document Has Been Signed on 10/17/2023 03:29 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	HARMONY HOME		FACILITY NUMBER:	374604054
ADMINISTRATOR:	ESCOBAR, CONNIE		FACILITY TYPE:	735
ADDRESS:	415 S. F STREET		TELEPHONE:	(760) 545-0119
CITY:	IMPERIAL	STATE: CA	ZIP CODE:	92251
CAPACITY:	4	CENSUS: 4	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Direct Support Provider Lucy Silvestre		TIME COMPLETED:	03:30 PM

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) Rebecca Ruiz conducted an unannounced Required 1-Year vist. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Direct Support Provider (DSP) Lucy Silvestre. LPA spoke to Administrator Connie Escobar on the telephone and House Manager Garrett Mazeroll arrived during the visit. The facility is licensed for a maximum capacity of 4 clients, 1 of which may be non-ambulatory. During today’s visit, the facility had a census of 4 clients, all of which were ambulatory. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Connie Escobar and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to the DSP Silvestre, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.3 degrees and 116.8 degrees Fahrenheit in 2 client bathrooms. The facility’s internal temperature was measured at 75 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HARMONY HOME	FACILITY NUMBER: 374604054
	VISIT DATE: 10/17/2023

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
26
27
28
29
30
31
32

LPA reviewed multiple client and staff records. Each client record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and cash resources, and personal rights. LPA reviewed clients’ personal and incidental money and ledger with DSP Silvestre and did not discover any inconsistencies. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and clients present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

An LIC9102 Technical Violation was issued regarding the facility's emergency disaster plan.

No deficiencies were cited on today's date. An exit interview was conducted with House Manager Garrett Mazeroll, whose signature below confirms receipt of a copy of this report, the LIC9102 TV, and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2