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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 03/11/2025
Date Signed: 03/11/2025 08:25:44 PM

Document Has Been Signed on 03/11/2025 08:25 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:
03/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Antonia DionisioTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On March 11, 2025, at 9:25 AM, Licensing Program Analysts (LPAs) Ernand Dabuet and Jose Anguiano conducted an unannounced case management visit to the facility in connection with complaint #11-AS-20250310121815. The LPAs met with the administrator, Antonia Dionisio, and explained the purpose of their visit.

During the visit, the LPAs reviewed the facility's Personnel Report (05/16/22) and found that Staff #3 was not listed in the California Department of Social Services Community Care Licensing Information System (LIS 531) or Guardian. Staff #3 did not obtain a Criminal Record Clearance 873559(e)(1) before working, residing, or volunteering in the licensed facility. As per regulations, all individuals must undergo a criminal record clearance. The administrator confirmed that Staff #3 did not have a Criminal Record Clearance prior to employment at the facility.

Civil penalties were assessed, and an exit interview was conducted. The licensee was provided with a copy of their appeal rights, and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 03/11/2025 08:25 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/11/2025 at 12:15 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2025
Section Cited
CCR
8733559(e)(1)

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87355 Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee will ensure to adhere to Title 22 Reg. 873449 have all staff prior to working in a licensed faciltiy have been Criminal Record Clearance. Licensee will have staff #3 fingerprint clearance by POC 03/12/25.
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This requirement is not met as evidenced by:
Based on record review and interview, there's evidence Staff #3 is did not have Criminal Record Clearance prior to working at the facility. This violation which is an immediate health, safety or personal rights risk to persons in care.
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IMMEDICATE CIVIL PENALTIES

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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