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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005979
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:06:24 PM

Document Has Been Signed on 09/25/2025 12:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
306005979
ADMINISTRATOR/
DIRECTOR:		FERGUSON, KENNELLIEFACILITY TYPE:
740
ADDRESS:211 S ALICE WAYTELEPHONE:
(657) 220-4800
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 2DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Camille SantosTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On September 25, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted the facility administrator (AD) Camille Santos about the visit. For this visit, there are three staff members on duty, all of which are background cleared and associated. AD later arrived to assist with the inspection.

The PUB475 ‘See Something, Say Something’ poster was observed to be located by the front entrance. LPA observed the Administrator's Certificate for Camille Santos, which expires on May 6, 2026.

The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, three of which may be non-ambulatory, one may be bedridden, and three may be on hospice. LPA toured the interior and exterior portions of the facility with AD. For this visit, there are a total of two non-ambulatory residents in care, one of which is on hospice.

The facility is a single-story home. There are a total of five bedrooms, two of which are private resident rooms, two are shared resident rooms, and one serves as staff quarters. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and free of any hazards. LPA observed the staff quarters to be kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of two bathrooms, both of which are for residents and staff.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/25/2025 12:06 PM - It Cannot Be Edited


Created By: Garlli Tat On 09/25/2025 at 11:30 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 306005979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, there were two expired food items which posed a potential health, safety or personal rights risk to persons in care. Lemon & Pepper seasoning (Great Value brand) had an expiration date of July 20, 2025 and Tartar sauce (Kraft brand) had an expiration date of August 7, 2025.
POC Due Date: 09/30/2025
Plan of Correction
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The administrator disposed of food items immediately during the visit. Deficiency cleared. Administrator will review all food items on a weekly basis and dispose of any items that have exceeded the expiration dates.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 306005979
VISIT DATE: 09/25/2025
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Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be between 113.7 and 113.9 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Two food items were observed to exceed expiration dates. AD disposed of items immediately during the visit. Sharp items and knives were locked in the kitchen and inaccessible to residents in care. Fire extinguisher were charged, mounted and located in the kitchen and the living room. Fire extinguishers were dated and tagged on February 4, 2025. LPA observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA observed that the First Aid kit had all the required components. Medications were observed to be locked in a cabinet in the kitchen. Toxins were also observed to be locked in a cabinet below the sink in the kitchen, inaccessible to residents in care.



For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards or obstructions. There are two self-latching gates in the backyard that can be opened in case of an emergency. No bodies of water were observed.

Two out of two resident files and three out of five employee files were reviewed during this visit.

Based on today's observations, there is one deficiency being cited per Title 22 of the California Code of Regulations.

An exit interview was conducted with Camille Santos. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Right were reviewed.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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