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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:17:23 PM

Document Has Been Signed on 08/08/2024 12:17 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR/
DIRECTOR:		DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:17 AM
MET WITH:Antonia DionsioTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 08/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager 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 107.8 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. The facility has conducted emergency fire drills on a month basis. The last Fire Drill was on 07/05/24 10:40 am. A review of the Medication Administration Record (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: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 08/08/2024 12:17 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/08/2024 at 11:08 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified (Residentt #2) did not have an appraisal of individual service needs and CCL forms not fill out completely. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee will ensure that all resident"s have a complete resident file. Proof of correction will require for a complete fill out residents forms including needs/services plan appraisal. Proof of correction must be sent to LPA Dabuet by due date via email at ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87303(a)(c)
(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.
(c) All window screens shall be clean and maintained in good repair.


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 identified Room #5 window screen had a hole. The common bathroom shower area did not have a shower curtain for privacy. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee will adhere to Title 22 87303 Maintenance and Operation. Licensee will repair or replace window screen and purchase a shower curtain for the resident's bathroom. Proof of correction must be sent to LPA Dabuet by due date via email at ernand.dabuet@dss.ca.gov
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 08/08/2024
NARRATIVE
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/23/23 through 09/23/24. The facility has CCLD license annual due on 08/11/24.

An audit of residents #1-#4 (R1-R4) service files and staff #1-#4 (S1-S4) personnel files. The facility has the current administrator's certification on file for Antonia Dionisio #6033374740 Expiration 12/11/2024.

DEFICIENCIES:
  • Resident #2 who was admitted in June 2023 had missing needs/services appraisal and incomplete CCLD forms fill out completely.
  • Observation of window screen for room #5 has a hole and will need to repair/replace.
  • Observation of no shower curtain in resident's bathroom for privacy.


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: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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