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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 08:53:39 PM

Document Has Been Signed on 08/03/2021 08:53 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Antonio DionsioTIME COMPLETED:
03:30 PM
NARRATIVE
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On 08/03/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility and met with administrator Antonio Dionsio and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check.

During today's inspection, LPA observed one (1) common bathroom, lighting fixtures, refrigerator, and dishwasher all required some deep cleaning that will take away deep dirt and grime, as well as bacteria and germs. Furthermore, ants were present alongside the upper kitchen cabinets. LPA informed the administrator the facility should be maintained cleaned, safe and sanitary condition at all times. The licensee violates the California Code Regulations (CCR) Title 22, section 87303 (a).

Citations are issued and an exit interview is conducted with Antonia Dionsio.
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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Document Has Been Signed on 08/03/2021 08:53 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/03/2021 at 02:03 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.
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The licensee will ensure that the items listed under this deficiency have been corrected to ensure compliance with California Code of Regulations Title 22, Section 87303 and provide proof of correction to CCL by the POC due date of 08/13/21.
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This requirement is not met as evidenced by:

LPA observed on 08/03/21 the bathroom wall, lighting fixtures, refrigerator, and dishwasher all covered with dirt, grime and bacterial germs. This poses potential personal rights, health and safety risks to the persons in care.
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Type B
08/13/2021
Section Cited
CCR87303(a)

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87303 Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.
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The licensee will ensure to correct this deficiency by calling a professional pest control company to spray through the facility and ensure compliance with California Code of Regulations Title 22, Section 87303 and provide proof of correction to CCL by the POC due date of 08/13/21.
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This requirement is not met as evidenced by:

LPA observed on 08/03/21 the along the upper kitchen cabinets crawling ants were present. This poses potential personal rights, health and safety risks to the persons 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.
SUPERVISOR'S 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021


LIC809 (FAS) - (06/04)
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