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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 08/28/2023
Date Signed: 08/28/2023 07:41:21 PM

Document Has Been Signed on 08/28/2023 07:41 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:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Elmer Carlos and Antonia Dionisio TIME COMPLETED:
02:05 PM
NARRATIVE
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On 08/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with lead caregiver Elmer Carlos LPA explained the purpose of today’s visit. Carlos contacted the administrator Antonia Dionisio who later was present during the visit. The facility is licensed to operate for (6) non-ambulatory of which (2) maybe bedridden elderly adults ages 60 and above. Currently, the facility has (1) hospice resident in care. 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: (5) residents' rooms, (2) bathrooms, (1) staff bedroom, (1) staff bathroom, a living area, a dining area, a kitchen, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.8 degrees F. A comfortable temperature of 78 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 08/28/2023
NARRATIVE
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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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 08/08/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/23/22 through 09/22/23.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#5 (S1-S5) personnel files. Interviews were conducted with (5) residents. The facility has the current administrator's certification on file for Antonia Dionisio #6033374740 Expiration 12/11/2024. The facility is not current on annual dues and was provided with an invoice.

DEFICIENCIES:
Resident #1 who admitted in June 2023 had missing documentation and supported records on file.
Resident #2 with dementia did not have current medical and appraisal assessment on file.
Resident #3 was missing prescription Gabapentin 300mg in medication log for entire month of August 2023
Observation of cob webs throughout the hallways
Observation of an old sofa not disposed for several years.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).


An exit interview conducted with Antonia Dionisio a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2023 07:41 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/28/2023 at 12:07 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 (c)(5) Care of Persons with Dementia(c) Licensees...shall be responsible for ensuring the following:(5)...an annual medical assessment...a reappraisal done at least annually...shall include...resident’s dementia care needs. This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (record review)], the licensee did not comply with the section. LPA identified Resident #2 with dementia, did not have current annual medical and needs and appraisal assessement for 20223. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2023
Plan of Correction
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The administrator agreed to obtain a medical assessment and needs and appraisal for Resident #2 and will create a plan to ensure that each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov. by 9/11/23. The administrator may ask for an extension if more time is needed via email.

Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) the licensee did not comply with the section cited above.LPA observed cob webs in hallways. LPA identified old sofa in the driveway that has not been discarded in several years. These violaitons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2023
Plan of Correction
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The administrator agreed to do a deep cleaning of hallways. The old sofa will be discarded and scheduled for trash pick up. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov by 09/11/23. The administrator may ask for an extension if more time is needed via email.
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: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


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Document Has Been Signed on 08/28/2023 07:41 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/28/2023 at 12:25 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record revew)], the licensee did not comply with the section cited above. LPA identified Resident #3 was missing documentation of Gabapentin 300mg for the entire month of August 2023 in (MAR). This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2023
Plan of Correction
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The administrator will ensure to review Title 22 Reg 87465 and retrained staff on administration of medications to residents in care. Administrator will send a written plan stating Reg 87465 was reviewed and staff have been retrained. POC must be submitted before due date 09/11/23. Proof of correction must be sent to ernand.dabuet@dss.ca.gov.
Type B
Section Cited
CCR
87505
7505 Documentation and Support Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in Section 87458, Medical Assessment.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified Resident #1 who was admitted in June 2023 was missing documentation and support in service file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2023
Plan of Correction
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The administrator will ensure to review Title 22 Reg 87505 and maintain all the required documentation and support records for Resident #1. Administrator will send proof of correction to LPA Dabuet by email at ernand.dabuet@dss.ca.gov by 09/11/23.
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: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


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