Harmony Care House

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Type of visit: Case Management - Other

LPA K. Nguyen conducted a face to face Component III presentation on 09/05/25 starting at 8:30 am. LPA met with licensee and administrator respectively, Nalini Nath. LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed participant gained knowledge about running and maintaining the facility in accordance with regulations. Exit interview conducted with Nalini Nath a copy provided.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Case Management - Other

At around 9:30 am, Licensing Program Analyst (LPA) K. Nguyen arrived to conduct final pre licensing inspection and met with previous Administrator, Shirley Marshall. LPA was informed that Licensee and Administrator Nalini Nath is currently out of town. LPA checked: - trash bins on driveway is not overflow with trashed - inside the dishwasher and are not being used as storage. - activities and resident drawer handle have been fix/ replaced - observed shared bathroom are clean - observed broken title in the share bathroom fixed - observed in resident room that Corinz and cleaning product on top of the drawer (Shared room) have been removed Report continued LIC809c... -observed Isopropyl Alcohol and dry shampoo in resident drawer (shared room) is removed and cleared - observed one nail polished inside the med chart, and multiple nail polishes left unlock on the shelve have been cleared and removed - observed resident medication are locked in the drawer - observed that Lysol cleaning wipe are locked in cabinet - observed room 3 shared closet is clear - observed room 7, 6, and 4 do not have a strong odor - observed chemical lock in the drawer near the laundry room - observed the wood on the patio have a hole and lift up have be fix - observed that all the piles of wood in between the two building have been removed After today's visit, the Pre-licensing inspection LPA have to conduct another visit to complete the COMP III, due to Administrator/ Licensee is out of town. Copy of report provided to the previous Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Prelicensing

On 5/19/2025 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Pre-licensed and Comp III inspection. LPA met with administrator; Shirley Marshall currently holds a certificate (#6005261740) that expired on 06/26/2025. Licenses Nalini Nath was informed and arrived at a later time. The facility’s fire clearance was approved for sixteen (16) non-ambulatory residents. LPA observed two residents in the dinning room. With Shirley, LPA inspected the physical plant including but not limited to 4 bedrooms, 4 bathrooms, living room, kitchen/dining area, laundry, and the outdoor area. The facility is a 1-storey building that has 8 designated resident rooms. Other rooms observed were designated for dining, activity and laundry. There is also a room designated as an office. The rooms are provided with drawers, nightstand lamps, sidewall lamp by the bed, closets, drawers, chairs and beds with mattress, box springs, linens, bed sheets, comforters, mattress pads, pillows with pillowcases. There are 4 common toilet/bathroom at the facility. All resident bathrooms/toilets are equipped with grab bars. All exit doors are installed with alarm/auditory signals. Toiletry supplies, bedsheets, linens, towels, paper towels and toilet papers are available. First Aid kit was checked and observed to be complete with manual. Water temperature in the shared bathroom was tested at 115.2 degrees Fahrenheit. Facility had flashlights for emergencies. There were 3 lights in the hallway. There is a locked cabinet for medications in the kitchen. The facility had a written emergency disaster plan. Smoke detectors were interconnected. Currently, there is a working telephone located in the office. Administrator states 2 additional extension phones will be installed by 2/15/18. Varied activity supplies residents were observed. There were non-perishable and perishable foods observed. Weekly menu is available. Dishes, glasses, and utensils are sufficient for the residents’ use. There was sufficient supply of warm blankets, hand towels, face towels and hand towels observed. continuation on Lic 809C Multiple fire extinguishers were observed and showed purchased date on 2/23/2025. Several carbon monoxide detectors were observed and tested functional. LPA observed the following deficiencies: At around 10am, LPA observed trash bins on driveway is overflow with trashed and on the ground At around 10:10am, LPA observed pizza slicer inside the dishwasher. Dishwasher used as storage. At around 10:30am, LPA observed activities and resident drawer handle is broken and are missing At around 10:33am, LPA observed shared bathroom are not clean At around 10:35am, LPA observed broken title in the share bathroom At around 10:40am, LPA observed in resident room contain a Corinz and cleaning product on top of the drawer (Shared room) At around 10:45am, LPA observed Isopropyl Alcohol and dry shampoo in resident drawer (shared room) At around 10:50am, LPA observed one nail polished inside the med chart, and multiple nail polishes left unlock on the shelve At around 10:51am, LPA observed resident medication left unlocked in the drawer At around 10:50am, LPA observed Lysol cleaning wipe outside in the back of the facility At around 10:55am, LPA observed room 3 shared closet is being used as a storage At around 10:55am, LPA observed room 7, 6, and 4 have a strong odor At around 10:55am, LPA observed chemical left unlock in the drawer near the laundry room At around 11:00am, LPA observed the wood on the patio have a whole and lift up Prior to licensure, the following is to be faxed to CCL by 5/23/25 : This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Comp III will be conduct after all POC is submit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 16 Census (if any clients in care): 13 Method: Telephone call with CAB COMP II Participants: Nalini Nath, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 1, 2025