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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 04/17/2023
Date Signed: 04/17/2023 04:51:19 PM

Document Has Been Signed on 04/17/2023 04:51 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:LIBERTY HARMONYFACILITY NUMBER:
374604207
ADMINISTRATOR:MANIPON, CHERIFERFACILITY TYPE:
737
ADDRESS:2915 DUCK POND LANETELEPHONE:
(760) 975-7176
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
04/17/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:DSP Justin Griggs and Quality Assurance Manager Morgan DavisTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Justin Griggs. LPA also met with Quality Assurance Manager Morgan Davis, who arrived later during the visit.

The facility currently operates under a two-year probationary facility license from CCLD, the result of an 08-22-2022 Stipulation, Waiver, and Order (SWO). During today’s visit, LPA conducted a general overall inspection of the facility, interviewed staff, reviewed records, and evaluated licensee’s ongoing compliance with the requirements described in the SWO.

Staff interviews, corroborated by record review, essentially supported: a) licensee has designated an “Orientation Trainer” who conducts new hire and other training for staff; b) licensee has a “Quality Assurance Manager” who meets with the facility’s program at least manager monthly to discuss training; c) licensee has a “Quality Assurance Team” to conduct quarterly internal audits; d) results of such internal audits are forwarded to the Department of Developmental Services (DDS), the San Diego Regional Center (SDRC), the CCLD San Diego Regional Office (RO), and licensee’s board of officers/directors; and, e) the board of officers/directors discuss such audit results at their board meetings. They also supported: f) licensee conducts Clients’ Personal Rights training for staff twice a year, g) licensee reviews incident reports at least monthly to ensure timely submission; and, h) licensee implemented required practices regarding medication management and communication between direct care staff and management (as described in the SWO).

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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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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: LIBERTY HARMONY
FACILITY NUMBER: 374604207
VISIT DATE: 04/17/2023
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[CONTINUED FROM LIC 809]

During today’s visit, the facility was clean, safe, sanitary, and in good repair. Staff training records were complete and current. There were no immediate health or safety concerns. The facility was operating consistent with the terms of the SWO. No deficiencies were observed or issued as part of this compliance visit.

An exit interview was conducted with Davis, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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