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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600806
Report Date: 03/17/2022
Date Signed: 03/18/2022 09:33:18 AM


Document Has Been Signed on 03/18/2022 09:33 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HARMONY ASSISTED LIVING OF SAN MATEOFACILITY NUMBER:
415600806
ADMINISTRATOR:SANDOVAL, TERRIFACILITY TYPE:
740
ADDRESS:1818 ROYAL AVENUETELEPHONE:
(650) 212-0244
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 1DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Terri SandovalTIME COMPLETED:
02:45 PM
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 3 bedrooms, two bathrooms, kitchen and living room. There is an enclosed patio and backyard. There is a 2 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. At this time, facility is family operated. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There is 1 resident present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Terri Sandoval is a certified RCFE administrator (x 10/22) that oversees facility operations.

The following updated forms/information are provided to LPA:

• Current liability insurance
• LIC 500 Personnel Report

No deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed.
See Technical Advisory Notes for additional information.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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