<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600977
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:27:39 PM

Document Has Been Signed on 08/26/2024 12:27 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HARMONY HOMEFACILITY NUMBER:
415600977
ADMINISTRATOR/
DIRECTOR:
FUJII, ROGERFACILITY TYPE:
734
ADDRESS:2790 COTTONWOOD DRIVETELEPHONE:
(650) 634-8316
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Aurora AcademiaTIME VISIT/
INSPECTION COMPLETED:
12:30 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
LPA Jeung toured facility and grounds, including attached garage--where washer and dryer are located-- of this Adult Residential Facility for Persons with Special Healthcare Needs. There are 4 private client rooms, each with exits to outside. Facility maintains facility-wide waivers for full bed rails for all clients' beds and alternative assistance with administering PRN medications. Electronic hoyer lifts are installed in all bedrooms and bathroom for lifting residents. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients. A comfortable temperature is maintained. Bathing facilities for clients are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 107 degrees in clients' bathroom. Food and PPE supplies and first-aid kit are inspected. Client records are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. There is no staff room, as facility employs awake night staff.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Roger Fujii is a certified ARF administrator (x 1/25) that oversees facility operations.

Proof of current surety bonding is requested to be sent to CCLD by 8/30/24.

No deficiencies of the California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
Facility is operating in substantial compliance.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 1