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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002550
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:36:50 PM

Document Has Been Signed on 11/29/2022 03:36 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HARMONY HOMEFACILITY NUMBER:
347002550
ADMINISTRATOR:CATA, CORNELIAFACILITY TYPE:
740
ADDRESS:5000 MELVIN DRIVETELEPHONE:
(916) 485-5541
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cornelia CataTIME COMPLETED:
03:50 PM
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On 11/29/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required- 1 Year annual inspection utilizing the infection control domain. LPA met with Caregiver, Emidio Arreola, and explained the purpose of the visit. Administrator arrived at the facility shortly afterwards. Prior to initiating the inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

The facility has 2 ambulatory and 4 non-ambulatory residents, 1 resident is currently on hospice services. Facility is licensed for 4 non-ambulatory and hospice waiver of 4. During this visit, LPA reviewed 6 out of 6 resident files.

LPA and Administrator toured the interior of the facility including bathroom, resident bedrooms, laundry room, kitchen, and common areas. In the areas toured, no immediate health, safety, and personal rights violation were observed. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishable foods. LPA observed paper towels, soap and hand washing signs in bathroom. LPA observed sharps, toxics and medication to be locked and secured. LPA observed Administrator Certificate #6025206740 to be up to date. LPA completed the infection control domain and at this time the facility was found to be at substantial compliance.

LPA requested copy of LIC 500 Personnel Report, LIC 308 Designation of Facility Responsibility, Administrator Certificate and current Liability Insurance to be emailed to LPA Yang by Friday December 9, 2022.

As a result of today's inspection, no deficiencies were observed.

Exit interview was conducted. A copy of report was left at facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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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