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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 10/08/2022
Date Signed: 10/08/2022 04:10:15 PM

Document Has Been Signed on 10/08/2022 04:10 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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:
10/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Elmer Carlos TIME COMPLETED:
04:29 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
On 10/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Antonia Dionisio and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory and may be (2) bedridden elderly residents ages 60 and above. The facility is approved for (1) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, three (3) common bathrooms, one (1) staff room, a living area, a dining area, a kitchen, and an outside area.

LPA toured the physical plant. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be operational. The water temperature measured 105.6 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (1) fire extinguisher that is charged, and smoke detectors operable. A working landline telephone remains available. The facility has a current liability insurance effective 09/21/22 - 09/21/23. The last fire drill was conducted on 10/6/22.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2022
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 5
Document Has Been Signed on 10/08/2022 04:10 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/08/2022 at 03:25 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
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation), the licensee did not comply with the section cited above. LPA identified cleaning solutions and sharp kitchen ojects in unlocked drawers and cabinets accessible to residents in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2022
Plan of Correction
1
2
3
4
The licensee will adhere to regulations 87309 and ensure to have medications are in locked storage units at all times. The licensee will send proof of correction by POC 10/09/22.
*This violation is corrected during visit.*
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/08/2022 04:10 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/08/2022 at 03:26 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
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation), the licensee did not comply with the section cited above . LPA identified bathroom #2 with a missing window screen. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2022
Plan of Correction
1
2
3
4
The licensee will adhere to regulations 87303 and ensure to repair/replace missing screen. The licensee will send proof of correction by POC 10/22/22.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation), the licensee did not comply with the section cited above . LPA identified stove hood, oven, and dishwasher filled with dirt grime and grease. The appliances are unsanitary. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
1
2
3
4
The licensee will adhere to regulations 87555 and deep clean stove hood, oven and dishwasher. The licensee will send proof of correction by POC 11/08/22.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/08/2022 04:10 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/08/2022 at 03:27 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
MONTEREY PARK, CA 91754

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(2)
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) , the licensee did not comply with the section cited above. LPA identified at 2:02pm mediation closet was unlocked and accessible to residents in care. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2022
Plan of Correction
1
2
3
4
The licensee will adhere to regulations 87465 and ensure to have medications are in locked storage units at all times. The licensee will send proof of correction by POC 10/09/22.
*This violation is corrected during visit.*
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 10/08/2022
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
26
27
28
29
30
31
32
INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
LPA identified the kitchen stove, over hood vent, oven and dishwasher unsanitary. LPA in bathroom #2 a missing screen window. LPA observed medication closet, kitchen drawer, laundry cabinets unlocked and accessible to residents in care.

Deficiencies are issued and an exit interview is conducted with Antonia Dionisio. A copy of this report is provided along with the appeal rights
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5