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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601704
Report Date: 11/07/2022
Date Signed: 11/07/2022 04:50:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220907154442
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:
11/07/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:ANTONIA DIONSIO.TIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Facility did not issue residents a copy of the contract.
INVESTIGATION FINDINGS:
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On 11/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to the facility and was greeted by Administrator Antonia Dionsio staff #1 (S1). LPA explained the purpose of the visit is to investigate the allegation mentioned on this complaint.

The investigation consisted of the following: LPA initiated an investigation for the above-mentioned allegation and interviewed with staff #1-#2 (S1-S2) . LPA requested copies of the following: staff and resident rosters and a review of resident #1 (R1's) service records. A tour of the facility was conducted.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20220907154442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/07/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility did not issue residents a copy of the contract.

The complainant requested for The Department to investigate the allegation "Facility did not issue residents a copy of the contract". According to the complainant, the facility failed to provide a copy of the (contract) Admissions Agreement for resident #1 (R1). (R1) was admitted at this facility on 01/2822 and the family representative was not provided a copy of the signed Admissions Agreement. on 01/27/22. According to the complainant, requests were made with the administrator on 02/19/22, 06/09//22, 06/25/22, and 06/29/22 with no response from the administrator. Interview with the administrator staff #1 (S1) stated (R1) was a resident at this facility from 01/28/22 through 05/23/22. (R1) was admitted at Torrance Memorial on 05/08/22 due to a fall and later admitted again at Kaiser Hospital on 05/23/22 due to weakness. According to (S1), (R1) did not return to the facility as (R1) required a higher level of care. (S1) admitted not providing a copy of the contract when (R1) was admitted on 01/28/22. (S1) states she later honored the request to (R1's) family representative and sent a copy by USPS mail sometime in July 2022. However, (S1) did not have proof a copy was sent nor was staff #2 (S2) able to verify (S1's) claim.

In the course of the investigation, it was revealed that the facility failed to submit a written incident report to Community Care Licensing, Long Term Ombudsman, the primary physician, and the family representative of (R1) during an incident on 05/08/22 and 05/23/22.

Based on the Department's observation and interviews, record reviews, and analysis, the preponderance of evidence standard has been met, therefore the allegation of "Facility did not issue residents a copy of the contract" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is cited on the attached LIC 9099-D.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220907154442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited
CCR
87507(e)
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87507 Admission Agreements
(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative...
This requirement is not met as evidenced by:
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The administrator will review Title 22 Sec. 87507 and agreed to send a copy of the contract to (R1's) family representative by USPS Certified Mail. The Administrator will send proof of correction to LPA by POC due date: 11/14/22.

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Based on the interview and record review and interviews, the administrator did not comply with the section cited above. The facility failed to provide a copy of the admissions agreement to (R1's) family representative. This violation poses a potential health, safety, or personal rights risk to persons in care.
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Type B
11/14/2022
Section Cited
CCR
82711(a)(B)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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The administrator will review Title 22 Sec. 87211 and agreed to send incident reports for (R1) for dates 05/08/22 & 05/23/22. The administrator will send the correction to LPA by POC due date: 11/14/22.
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Based on interview and record review, and interviews, the administrator did not comply with the section cited above. The facility failed to send written incident reports to CCLD. This violation poses a potential health, safety, or personal rights risk to 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3