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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601704
Report Date: 09/13/2026
Date Signed: 09/13/2026 02:17:00 PM

Document Has Been Signed on 09/13/2026 02:17 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HARMONY HOME CAREFACILITY NUMBER:
198601704
ADMINISTRATOR/
DIRECTOR:		DIONSIO, ANTONIAFACILITY TYPE:
740
ADDRESS:1318 215TH STREETTELEPHONE:
(310) 549-0218
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 4DATE:
09/13/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Antonia DionisioTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On September 13, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced 1 Year Required annual inspection visit. LPA met with administrator Antonia Dionisio. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory of which (2) maybe bedridden elderly adults ages 60 and above. The facility is approved for (1) hospice resident. Currently there is no hospice resident in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) residents' rooms, (2) bathrooms, (1) staff bedroom, (1) staff bathroom, a living area, a dining area, a kitchen, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. The facility has conducted a Fire Drill on 09/03/26. A review of the Medication Administration Record (MAR) was observed to be maintained in order.
(Evaluation Report continues LIC 809-C)
Janae Hammond
Ernand Dabuet
DATE: 09/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2026
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 09/13/2026 02:17 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/13/2026 at 12:52 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2026
Section Cited
CCR
87411)(a)

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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Licensee must comply with Title 22 Section 87411 and ensure at all times be sufficient in numbers with staff to meet residents needs. Proof of correction with LIC 500 must be submitted by the due date of 09/27/26 to 424-544-1016.
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This requirement is not met as evidence by:
Based on record review, Licensee did not have a wake staff for NOC shift to attend to (3) non-ambulatory, incontinence residents. This violation possesses a potential Health and Safety risk to residents in care.
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Type B
09/27/2026
Section Cited
CCR87458(a)(1)(A)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...(1) A physical examination..(A) Communicable tuberculosis.
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Licensee must comply with Title 22 Section 87456 and ensure that all residents when admitted have TB examination with results. Proof of correction, must be submitted by the due date of 09/27/26 to 424-544-1016.
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This requirement is not met as evidence by:
Based on record review,Resident 3 did not have TB examination with results when admitted. This violation possesses a potential Health and Safety risk to residents in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2026


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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HARMONY HOME CARE
FACILITY NUMBER: 198601704
VISIT DATE: 09/13/2026
NARRATIVE
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/23/25 through 09/23/26. The facility is current on CCL License dues.

An audit of residents #1-#4 (R1-R4) service files and staff #1-#3 (S1-S3) personnel files. The facility has the current administrator's certification on file for Antonia Dionisio #8740 Expiration 12/11/2026.

DEFICIENCIES:
  • Resident #3 did not have a TB examination test results on file.
  • Facility is insufficient in staff and did not have a night shift supervision (wake staff) NOC to meet residents needs.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).


An exit interview conducted with Antonia Dionisio a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

Note: Due to technical difficulties, LPA was unable to generate an electronic inspection tool and instead used a printable/PDF version.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2026
LIC809 (FAS) - (06/04)
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