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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294136
Report Date: 09/28/2026
Date Signed: 09/28/2026 12:18:11 PM

Document Has Been Signed on 09/28/2026 12:18 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HARMONIE HOMEFACILITY NUMBER:
435294136
ADMINISTRATOR/
DIRECTOR:		HERNANDO, MA LORAINEFACILITY TYPE:
740
ADDRESS:1463 NESBIT COURTTELEPHONE:
(408) 997-7925
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY: 6CENSUS: 6DATE:
09/28/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Daniel MabunayTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced follow-up Case Management visit. LPA announced the purpose of the visit and met with Daniel Mabunay, Administrator.

On 07/02/26 the department received an SOC341 for an incident that occurred on 06/16/26. On 06/16/26 the facility reported of a Staff, (S1) that was using intimidation tactics including forcefully banging on the table.
On 07/08/26 LPA conducted an initial Case Management visit and interviewed staff and Adminsitrator.
S2 and S3 stated S1 verbally abused R1 and said derogatory remarks. S2 and S3 stated that S1 would hide the reclining chair remote so R1 would not be able to use the recliner because S1 would get upset and wanted R1 to sleep in his/her room. S2 and S3 stated on one occasion observed R1s diaper fall off and he/she kicked it to avoid walking on it and S1 grabbed diaper and threw it back toward R1s walkway.
ADM stated she was not aware of the behavior and staff had not reported any of the incidents because S1 would threaten them that he/she was the boss.

During visit LPA toured the facility and observed residents eating lunch.

LPA determined this Case Management closed.

Deficiencies are being cited during today's visit see LIC809D. This report was reviewed with Daniel Mabunay and a copy of the signed report was provided. Appeal rights were provided.
Christine Kabariti
Marcela Yanez
DATE: 09/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2026
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 09/28/2026 12:18 PM - It Cannot Be Edited


Created By: Marcela Yanez On 09/28/2026 at 11:25 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HARMONIE HOME
FACILITY NUMBER: 435294136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2026
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of residents in all facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights.(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by:
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ADM will submit a letter of understanding of regulation and conduct staff trainings on Residents Rights. ADM will submit POC by due date 09/29/2026 to LPA via e-mail.
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Based on interviews the licensee did not comply with the section cited above. S1 used intimidation tactics toward R1 and verbally abused R1. This poses/posed a immediate health, safety or personal rights risk to persons 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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2026 12:18 PM - It Cannot Be Edited


Created By: Marcela Yanez On 09/28/2026 at 11:52 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HARMONIE HOME
FACILITY NUMBER: 435294136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2026
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency... including, (1) A written report shall be submitted to the licensing agency ... within seven days ...(D)Any incident which threatens the welfare, safety or health of any resident ...The requirement was not met as evidenced by:
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ADM will ubmit a letter of understanding of regulation and conduct training on Mandatory reporting by POC due date 10/07/26.
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Based on the records reviewed, the facility did not send the incident report of resident R1 within 7 days of the incident occurrence, this poses a potential health, safety risk to persons 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.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2026


LIC809 (FAS) - (06/04)
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