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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006616
Report Date: 02/04/2025
Date Signed: 02/04/2025 10:52:18 AM

Document Has Been Signed on 02/04/2025 10:52 AM - 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 GROVE ASSISTED LIVINGFACILITY NUMBER:
306006616
ADMINISTRATOR/
DIRECTOR:		SILVA, ALEXANDREFACILITY TYPE:
740
ADDRESS:703 N CAMBRIA STTELEPHONE:
(909) 839-3435
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: DATE:
02/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:22 AM
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Licensing Program Analyst (LPA) Samer Haddadin made an announced visit to conduct a Pre-licensing . LPA was greeted and granted entry by Administrator (AD) Alex Silva.

The facility is one story a home with 4 bedrooms and two restrooms. The facility has an approved fire clearance of six none-ambulatory residents in which one maybe bedridden and hospice waiver for 6, Facility had no residents in care at the time of visit.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in both restrooms, and testing auditory devices on all exits. The hot water temperature measured between 112.4- and 114.6-degrees Fahrenheit, and all smoke detectors were operational. Restrooms toilets and water faucets were also observed to be operational. Grab bars were secure, and showers were observed to be free of mold/mildew. The fire extinguisher is charged with last inspected date of October 31, 2024.
LPA inspected the exterior of the facility, and the facility has no bodies of water (pool) . LPA also observed a shaded seating area for residents’ enjoyment. LPA checked outside emergency exits to be functioning and free of obstacles.

LPA inspected the facility food supply and observed the facility retained seven days of non-perishable food on hand and will have two days of perishable items once there are residents in care. Knives and cleaning supplies are secured in a separate cabinet located in the kitchen.


LPA observed medication storage and a First Aid Kit with all the required components and medication storage is locked in kitchen cabinet. LPA observed all required department postings by the entrance.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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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 GROVE ASSISTED LIVING
FACILITY NUMBER: 306006616
VISIT DATE: 02/04/2025
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 LPA confirmed that administrator has a current administrator certificate which expires on October 30th 2nd, 2026. LPA conducted Component III with Administrator.

The Administrator was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of the report was provided to Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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