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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 08/03/2021
Date Signed: 08/03/2021 08:51:02 PM

Document Has Been Signed on 08/03/2021 08:51 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR:DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:ANTONIA DIONSIOTIME COMPLETED:
01:52 PM
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On 08/03/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Antonia Dionsio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which two (2) maybe bedridden. The facility is approved for one (1) hospice waiver. Currently, the facility has six (6) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, three (3) bathroom bathrooms, living area, dining area, kitchen, laundry room, and garage used for storage.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were observed, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were stocked at the time of visit. Bathrooms were found to be operational. The water temperature measured 105.9 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was observed to be maintained in order and accurate. A landline phone is working in condition.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 08/03/2021
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During the visit, LPA observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the staff and resident's COVID tests and vaccination results was conducted. A Mitigation Plan Report is filed with CCLD.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted, and a copy of this report was provided to Antonio Dionsio by email.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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