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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 02/20/2024
Date Signed: 02/20/2024 12:50:10 PM

Document Has Been Signed on 02/20/2024 12:50 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:
02/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Assistant Program Director Cruz MoraTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assistant Program Director Cruz Mora.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 01/11/2024), involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. According to the SOC341, Licensee received the following allegation: after C1 had an episode of incontinence on 01/09/2024, staff did not timely clean C1 and change their clothing.

During today’s visit, C1 was off-site at a day program, along with two (2) of their house mates. LPA performed a brief facility tour and welfare check on the one (1) house mate who was present, finding no safety concerns. LPA also interviewed relevant staff and collected copies of and reviewed pertinent records.

According to C1’s latest LIC602 Physician’s Report (dated 09/07/2023), C1 was diagnosed with Autism and Schizoaffective Disorder. C1’s physician noted that C1 wore absorbent underwear due to urinary incontinence.

Records and interviews showed: Upon learning of the allegation, Licensee timely notified San Diego Regional Center (SDRC) and performed an internal investigation. Interviews of all eight (8) line staff who were on duty during the incident, plus two (2) managers, widely corroborated that C1 was timely showered and changed following their incontinence episode.


[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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: 02/20/2024
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[CONTINUED FROM LIC 809]

Based on the evidence, no deficiencies were cited for the incident. Also, no deficiencies were observed during today’s visit.

An exit interview was conducted with Mora, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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