198601704-10-7-2025-11-AS-JHAD-DMPQNP-20251022121928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601704
Report Date: 10/07/2025
Date Signed: 10/07/2025 05:11:40 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250310121815

FACILITY NAME:	HARMONY HOME CARE		FACILITY NUMBER:	198601704
ADMINISTRATOR:	DIONSIO, ANTONIA		FACILITY TYPE:	740
ADDRESS:	1318 215TH STREET		TELEPHONE:	(310) 549-0218
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Antonia Dionisio		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Facility retained resident with prohibited health condition.

INVESTIGATION FINDINGS:

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On October 07, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegation mentioned above.

The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff members #1 (S1) and Resident members #2 to #5 (R2-R5) and Witness #1 (W1) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), (R1's) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24), Los Angeles County Sheriff's Department Incident Report (dated 03/09/25) and Harbor UCLA Medical Records Medical Records (dated 03/25/25) and other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250310121815

FACILITY NAME:	HARMONY HOME CARE		FACILITY NUMBER:	198601704
ADMINISTRATOR:	DIONSIO, ANTONIA		FACILITY TYPE:	740
ADDRESS:	1318 215TH STREET		TELEPHONE:	(310) 549-0218
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Antonia Dionisio		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Staff dispensed wrong medication not prescribed to resident.
Staff did not provide nutritious snacks for residents.
Staff inappropriately touched the resident.

INVESTIGATION FINDINGS:

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On October 07, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegations mentioned above.

The investigation included interviews, a record collection, and a tour of the facility. Interviews with Staff members #1-#2 (S1-S2) and Resident members #2 to #5 (R2-R5) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), Resident #1 to #5 (R1-R5)'s Physician Report, Medication Administration Record, Appraisal/Needs and Service Plan, Los Angeles County Sheriff Department Incident Report (dated 03/09/25) and other records pertinent to this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #7: Staff dispensed wrong medication not prescribed to resident.

It is alleged that the facility staff administered incorrect medications that were not prescribed for Resident #1 (R1). Reports indicate that medications intended for other residents were given to (R1) when (R1's) prescriptions were not refilled. The specific dates and types of medicines involved have not been provided. No further details are available regarding this matter.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to validate this claim. (R2-R4) expressed that the staff closely observes the medications for each resident. They have never received incorrect medications or experienced issues with refills.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) claim this accusation is false. (S1-S2) claimed to follow the Seven Rights of Medication Administration to ensure safe and effective medication delivery to prevent medication errors and protect residents' safety. (S1) indicated that (R1) is alert and can recognize the medications given to (R1) by the staff. (R1) is also able to administer (R1's) meds and store their own medications as ordered by (R1's) physician.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) communicated a clear understanding of (R1's) medication needs, stating that while (R1) may not be familiar with the specific types of medications being dispensed, (R1) is committed to taking only those prescribed by (R1's) doctor. Moreover, (R1) expressed independence by indicating (R1's) ability to manage and store (R1's) own medications. However, (R1) emphasized a preference for staff assistance with this task.

The Department reviewed (R1’s) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24). The Department confirmed that (R1) can administer and store its own prescription medications, with staff assistance provided as needed.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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Additional review of (R1’s) Centrally Stored Medication and Destruction Record and Medication Administration Record (dated 01/01/25 through 03/10/25) confirmed the accuracy and compliance of (R1’s) medications, revealing no omission, errors or discrepancies.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

ALLEGATION #8: Staff did not provide nutritious snacks for residents.

It is alleged that the facility staff does not provide nutritious snacks for Resident # (R1). Reports indicate that staff gave (R1) large bags of M&M’s, despite knowing that (R1) is diabetic, and there is no monitoring of (R1’s) intake of sweets. No further details regarding this matter have been provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) expressed that the staff monitors their meal and snack intake and have no concerns regarding the meals or snacks provided. They mentioned that the variety of meals and snacks is sufficient and meets nutritional standards.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff cannot valid this claim. Residents are provided with three meals and two snacks daily, all of which have nutritional value, according to (S1). (R1) receives diabetic-friendly meals and snacks that include high fiber, lean proteins, healthy fats, and controlled portion sizes. (R1's) snacks consist of cottage cheese, yogurt, energy bars, fruits, and vegetables. Additionally, (R1) occasionally brings personal snacks, which may include dark chocolate and sugary candies. These personal snacks are monitored by staff when notified that (R1) has brought treats.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) stated that the facility staff consistently provided adequate meals and snacks that met essential nutritional standards. Additionally, (R1) expressed a clear preference for (R1's) personal snacks over those offered by the staff, indicating that this choice was based on individual taste.

On March 11, 2025, and September 26, 2025, the Department conducted inspections of the food supply. The inspections revealed a variety of proteins, vegetables, fruits, whole grains, and other items, including bread, dairy products, eggs, and cereal.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of these allegations.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.

An exit interview was conducted with the administrator Antonia Dionisio, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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Ample non-perishable food supplies were available to last for at least one week, while perishable items were sufficient for a minimum of two days, in accordance with Title 22 regulations.

Further reviewed of (R1’s) Physician’s Report LIC 602A (dated 05/24/23) and Preplacement Appraisal Information LIC 603 (dated 08/08/24) revealed (R1) was not on any special diet or observation of food intake.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

ALLEGATION #9: Staff inappropriately touched the residents.

It is alleged that a staff member at the facility inappropriately touched Resident #1 (R1). During shower assistance, it was reported that staff made improper contact with (R1) in the genital area, which caused (R1) to feel disturbed about the incident. No further details regarding this matter have been provided.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to confirm this claim. (R2-R4) stated that the staff are professional and have not committed any improper conduct towards any of the residents.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff cannot support this accusation. (S1-S2) asserted that all residents are treated with dignity and respect. They emphasized that residents receive professional assistance with bathing. (S1) claimed that the accusation is fabricated, noting that Resident #1 (R1) is not assisted with baths or showers, but only receives assistance with sponge baths.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) stated that (R1) felt the staff at Harmony did not mistreat (R1) and was treated with respect. (R1) denied being a victim of physical or sexual abuse by any staff members. (R1) emphasized that there were no inappropriate interactions, as (R1) had established clear boundaries. Additionally, (R1) mentioned that the staff provided sponge baths instead of showers as (R1's) preference, and (R1) felt comfortable with the level of care provided.

A review of the Los Angeles County Sheriff Department Incident Report (dated 03/09/25), indicates that (R1) stated staff assisted with (R1’s) incontinence needs and confirmed that staff have not engaged in any inappropriate behavior towards (R1).

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Edward Hector.

As part of the investigation, Investigator Hector subpoenaed records from Harbor UCLA Medical and the Los Angeles County Sheriff's Department. The relevant records included the following: the Harbor UCLA Medical Records (dated 03/25/25), and the Los Angeles County Sheriff's Department Incident Report (dated 03/09/25). Additionally, Hector reviewed (R1's) Physician's Report LIC 602 (dated 05/24/23), Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24) as well as the Centrally Stored Medication and Destruction Record and the Medication Administration Record covering the period from 01/01/25, to 03/10/25. Furthermore, the investigator conducted interviews with Staff #1(S1), Witness #1 (W1), and Resident #1 (R1).

INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #1: Facility retained resident with prohibited health condition.

It is alleged that Resident #1 (R1) developed pressure injuries as a result of staff neglect. Reports indicate that (R1) developed stage 3 bedsores in the groin and buttocks area, which the facility failed to report or treat. Additionally, home health or hospice care services were not provided. No further details concerning this matter were available.

On March 2 and March 4, 2025, Resident #1 (R1) was admitted to Harbor-UCLA Medical Center due to abnormal labs and general weakness. Medical records revealed that a wound assessment was conducted, which showed a stage 3 pressure injury in the sacral/coccygeal area and another on the right hip ischium. The sacral/coccygeal wound measured 5 cm by 7 cm, while the pressure injury on the right ischium measured 3 cm by 10 cm.

On April 17, 2025, at 2:30 PM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Harmony Home for approximately 1.5 to 2 years. (R1) expressed experiencing bedsores in the buttocks area and mentioned having difficulty lying on the backside for extended periods due to these pressure injuries. (R1) indicated that no facility staff assisted with repositioning every two hours, and help was only provided when explicitly requested. Additionally, (R1) noted that while the facility applied some form of medication to the wounds, it was not done effectively. Furthermore, (R1) confirmed that no skilled nurse, hospice nurse, or home health nurse had come to address the pressure injuries.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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On April 17, 2025, at 3:35 p.m., the Department interviewed Witness #1 (W1). (W1) reported observing facility staff applying cream and gauze to (R1's) buttocks. (W1) confirmed that (R1) did not receive any home health, hospice, or skilled nursing visits while residing at Harmony Home Care. Additionally, (W1) mentioned that (R1) had not received home health visits for a year before changing insurance carriers.

On April 17, 2025, at 5:01 p.m., the Department interviewed Staff #1 (S1), the facility administrator of Harmony Home Care. (S1) is responsible for training the staff to spot pressure injuries. (S1) instructs the staff to look for signs, such as redness or blisters, on the skin before an open wound. If staff see these symptoms, they must inform the administrator. The administrator will then contact the primary physician and family representatives to obtain a referral for home health or hospice services.

(S1) stated that the staff are trained to reposition residents every two to three hours. However, (S1) also mentioned that the staff do not get help with wound care. Additionally, (S1) noted that (R1) was receiving nursing visits to evaluate pressure injuries when admitted. (S1) revealed that (R1) has had ongoing pressure injuries "on and off" since being admitted to the facility.

(S1) claimed that (W1) canceled hospice services in September 2023. (S1) claims to have asked several times about reinstating (R1's) home health visits or transferring (R1) to another facility, but (W1) refused both options. (R1) has not received any hospice or home health visits, and no doctor or skilled nurse has visited in the past 30 days.

(S1) claimed that (R1) refused to let the facility staff reposition (R1) regularly to relieve pressure from the wounds. Additionally, (S1) could not provide any documentation of hospice records, incident reports, or wound care related to (R1's) pressure injuries. As a result, (R1) continues to experience pressure injuries due to poor circulation, having been bed-bound since admission.

The Department reviewed the following records: Harbor UCLA Medical Records (dated 03/25/25), Los Angeles County Sheriff Department Incident Report (dated 03/09/25), Windsor Convalescent Center Medical Records (dated 11/21/24), and Harbor UCLA Medical Records (dated 12/14/24). Notably, (R1) was assessed for Stage 3 pressure injuries. Further review of facility's written communications (dated 10/03/23) revealed (R1) was removed from hospice care services effective September 29, 2023.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 9 of 10

Control Number 11-AS-20250310121815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.	1 2 3 4 5 6 7	Licensee/Administrator shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 10/08/25 to ernand.dabuet@dss.ca.gov
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) history of pressure injuries and retained (R1) with a stage 3 prohibited health condition and failed to ensure proper care, such as hospice or home health care services, were provided for the wounds. This violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 10/08/2025 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.	1 2 3 4 5 6 7	Licensee/Administrator will review Title 22, Section 87615, of the regulation and submit a written review to ensure compliance with the regulations. Licensee will retrain staff on pressure injuries and submit completed training with staff name, and dated completed by POC date 10/08/25 to ernand.dabuet@dss.ca.gov
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) pressure injuries and retained (R1) with stage 3 wounds and failed to ensure proper care, such as hospice or home health care services, were not provided. This violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 10/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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