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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005397
Report Date: 11/23/2021
Date Signed: 11/23/2021 02:04:08 PM

Document Has Been Signed on 11/23/2021 02:04 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HARMONY DAY PROGRAMFACILITY NUMBER:
577005397
ADMINISTRATOR:VENTIMIGLIA, DOMINICFACILITY TYPE:
775
ADDRESS:1250 HARTER AVE, STE GTELEPHONE:
(530) 666-6146
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY: 30CENSUS: 18DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Sherry Williams, LVN, Program ManagerTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Sherry Williams, Program Manager. There were no clients present at the facility due to COVID-19; there are 18 clients participating through home visits or virtually at this point.

LPA arrived at the facility and had temperature checked and logged into visitor’s binder. During facility tour on 11/23/2021 with staff Sherry Williams; facility was found to be clean and at a comfortable temperature of 72 F with all exits free from obstruction. Clients' common areas, kitchen & food storage areas were inspected and found to be clean and ready for participants' return. Two (2) Fire Extinguishers were found to be charged on 09/16/2021. Smoke Detectors ,Carbon monoxide detectors and fire sprinkler system are maintained by Foothill Fire and Wire and were last inspected on 10/09/2021. There was a supply of cleaners, hygiene products
and other toxins which were stored in a locked cabinet under the kitchen sink and in a locked storage cabinet. Medications and sharps are kept in a locked med. cart in the med. room area.


Facility has submitted a mitigation program plan. Posters have been placed at entrance,;small table with hand sanitizer and other items designated for visitors and staff is placed at entrance. There have been no clients at facility since March of 2020. Staff self-screen before coming into work and check temperature before entry.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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