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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201516
Report Date: 10/06/2026
Date Signed: 10/06/2026 02:08:12 PM

Document Has Been Signed on 10/06/2026 02:08 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HARMONY CARE HOUSE LLCFACILITY NUMBER:
019201516
ADMINISTRATOR/
DIRECTOR:		NATH,NALINIFACILITY TYPE:
740
ADDRESS:565 SCHAFER ROADTELEPHONE:
(510) 701-3807
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 16CENSUS: 13DATE:
10/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nalini Nath, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 10/06/2026 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced annual inspection. LPA met with the Lead Staff, Shirley Marshall. LPA informed Administrator (ADM) Nalini Nath, who arrived at a later. The facility’s fire clearance was approved for sixteen (16) non-ambulatory residents.

LPA observed three residents in the dining room and three residents in the living room.

LPA inspected the physical plant with ADM, including 8 bedrooms, 2 bathrooms, the living room, the kitchen/dining area, the laundry, and the outdoor area. The facility is a 1-story building that has 8 designated resident rooms. Other rooms observed were designated for dining, activity, and laundry.

The facility also has a room designated as an office. Rooms include drawers, night stand lamps, a sidewall lamp by the bed, closets, chairs, and beds with mattresses, box springs, linens, bed sheets, comforters, mattress pads, and pillows with pillowcases. All resident bathrooms/toilets are equipped with grab bars. All exit doors have alarm/auditory signals. Toiletry supplies, bedsheets, linens, towels, paper towels, and toilet paper are available. The first aid kit was checked and found complete, with a manual. LPA tested the water temperature in the shared bathroom at 112 degrees Fahrenheit.

Report Continue to LIC809...

Bennett Fong
Kelly Nguyen
DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2026
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 10/06/2026 02:08 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 10/06/2026 at 01:33 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARMONY CARE HOUSE LLC
FACILITY NUMBER: 019201516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having Clorox wipes on the counter near the kitchen unlock, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
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Administrator locked chemical during inspection; deficiency cleared. Administrator (ADM) agrees to conduct an in-service training course for all staff on the cited citation, including attendance and signatures from all staff. ADM agrees to provide a self-certification letter indicating understanding of the cited citation and submit it to CCLD by 10/9/26.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the office room containing medications was left unlocked, and the med cart in the living room containing prescribed medication (Rybelsus) was left unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
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Administrator locked up medication during inspection; deficiency cleared. Administrator (ADM) agrees to conduct an in-service training course for all staff on the cited citation, including attendance and signatures from all staff. ADM agrees to provide a self-certification letter indicating understanding of the cited citation and submit it to CCLD by 10/9/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2026


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HARMONY CARE HOUSE LLC
FACILITY NUMBER: 019201516
VISIT DATE: 10/06/2026
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The facility had flashlights for emergencies. The hallway had 3 lights. The facility had a written emergency disaster plan. Smoke detectors were interconnected. A working telephone is currently located in the office. The administrator states 2 additional extension phones will be installed by 2/15/18. Varied activity supplies for residents were observed. Non-perishable and perishable foods were observed. The weekly menu is available. Dishes, glasses, and utensils are sufficient for the residents’ use. A sufficient supply of warm blankets, hand towels, and face towels was observed. The emergency disaster plan was last updated on 9/16/26; a fire drill was conducted on 9/16/26. Fire extinguishers were full and last serviced on 3/11/2026.

LPA reviewed 6 residents' files and 4 staff files. 6 out of 6 residents have TB on file. 4 out of 4 staff have first aid and CRP on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

- At around 9:50 am LPA observed that the office room containing medications was left unlocked, and the med cart in the living room containing prescribed medication (Rybelsus) was left unlocked.

- At around 10 am LPA observed that Clorox wipes were on the counter near the kitchen

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by the POC date may result in additional Civil Penalties.

Exit interview conducted. Provided appeal rights and a copy of this report.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2026
LIC809 (FAS) - (06/04)
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