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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600977
Report Date: 07/17/2025
Date Signed: 07/18/2025 08:41:58 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/18/2025 08:41 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
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:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Freddie Academia, Angelita Rojas, Roger FujiiTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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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 113 degrees in clients' bathroom. Only one resident eats by mouth. Food--consisting of formula and regular food--PPE supplies and first-aid kit are maintained. Client records are reviewed, including Centrally Stored Medications Records and clients' cash resources logs.
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 1/27) that oversees facility operations.

The following information/forms are requested to be completed and sent to CCLD by 7/31/25:
- Affidavit Regarding Client Cash Resources (LIC400)
- Administrative Organization (LIC309)
- Personnel Report (LIC500)

Deficiency of the California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See also Technical Advisory Note--one page.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/18/2025 08:41 AM - It Cannot Be Edited


Created By: Audrey Jeung On 07/17/2025 at 06:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HARMONY HOME
FACILITY NUMBER: 415600977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited
HSC
1565(c)

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HEALTH & SAFETY CODE
... conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary...actual evacuation...is not required... Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.
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Quarter emergency drills will be conducted and documented, and proof of correction to be sent to CCLD BY DUE DATE
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This requirement is not met, as emergency drills are documented and conducted about 2x/year. Licensee failed to ensure that quarterly emergency drills are conducted, which poses a potential health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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