Harmony Home Care

Allegation investigated: Staff locked resident in the room. Staff do not properly prepare resident(s) meal. Staff do not provide resident with medical attention.

On 05/29/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with Staff and spoke with Administrator Antonia Dionsio over the phone. Investigation consisted of the following: On 05/29/2026, the Department obtained Resident #1 - #4 (R1 – R4) records, Resident #1 and #2 Medication Administration Record (April and May 2026) and interviewed Staff #1 - #3 (S1 – S3), Residents #3 - #4 (R3 – R4), and Witness #1 (W1). Investigation revealed the following: Allegation: Staff locked resident in the room. It is alleged staff tied a rope outside of the Resident #2’s (R2) door to prevent R2 from getting out and lock R2 in room. Record Review of R2’s Physician's Report (10/15/25) revealed R2's primary diagnosis is dementia with behaviors (disturbances), has a walker... Continue to LIC9099-C. Unsubstantiated ,can be confused/disoriented and have sundowning behavior. Review of Needs and Services Plan (10/10/25) revealed R2 is forgetful, can be agitated, and like a zombie at night. Staff is to keep reminding R2. R2 will not walk if R2 doesn’t like but if R2 likes to walk then staff cannot stop R2. The goal is for staff to help R2 walk and exercise every day. Three out of three staff interviews (S1 – S3) indicated they have not locked R2 in room. Two out of two residents (R3 – R4) indicated they are allowed to wander and move around the facility. R4 indicated R4 has not seen a rope tied outside of R2’s door and hears the staff run to R2 when R2 gets up. Witness #1 (W1), R2’s family member, indicated that the door is always open and denied the allegation. At 8:23 AM, LPA observed staff pushing R2 outside in walker. Regarding the allegation, “Staff locked resident in the room,” based on record review, interviews, and observation, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Allegation: Staff do not properly prepare resident(s) meal. It is alleged staff put chicken bones in Resident #1’s (R1) soup and casserole Record Review of Preplacement Appraisal (03/16/26) revealed R1 needs a soft food diet. Three out of three staff members indicated they consider the cultural and religious background and food habits of the residents. Staff #1 indicated the chicken is shredded and sometimes a bone may remain, but it is soft. Staff #2 indicated S2 has not received food (bone) complaints from R1. Staff #3 indicated bones are removed from the chicken soup. Two out of two resident interviews (R3 – R4) indicated an appropriate variety of foods with consideration for cultural and religious background and food habits is provided. Witness #1 (W1) indicated an appropriate variety of foods with consideration for cultural and religious background and food habits are provided for R2. Regarding the allegation, “Staff do not properly prepare resident(s) meal,” the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Continue to LIC9099-C. Allegation: Staff do not provide resident with medical attention. It is alleged staff would not assist Resident #1 (R1) and told R1 not to call 911. Three out of three staff members (S1 – S3) indicated they assist R1 with back pain and have not prevented R1 from calling emergency services. Staff #1 (S1) indicated emergency services would get upset with pain complaints but R1 has own cellphone and it is R1’s personal right. Staff #2 (S2) indicated R1 would call emergency services when S2 would not administer additional Lorazepam or when R1 could not feel the effect of the medication. S2 indicated S2 would accompany R1 outside and wait for emergency services. Two out of two resident interviews (R3 – R4) indicated staff provide or will seek medical attention when needed. Witness #1 (W1) indicated staff provide or will seek medical attention when R2 needs it. Regarding the allegation, “Staff do not provide resident with medical attention,” the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted and a hard copy was provided to Staff Susana Parungao.the state’s words, verbatim · CDSS document, May 29, 2026 · control 11-AS-20260521164025

Type of visit: Office

On November 20, 2025, an office meeting was held to discuss Complaint 11-AS-20250310121815. The attendees included Licensing Program Manager (LPM) Janae Hammond, Licensing Program Analyst (LPA) Ernand Dabuet, and Administrator Antonia Dionisio. During the meeting, the (LPM) reviewed the details of the complaint. On March 10, 2025, the Department substantiated an allegation of neglect and lack of care and supervision. Specifically, facility staff retained a resident with a prohibited health condition who required a higher level of care due to pressure injuries. When the findings were delivered on October 10, 2025, the Department indicated that an enhanced civil penalty determination was pending under Health and Safety Code Section 1569.49(f) for Serious Bodily Injury. The Department is currently reviewing the complaint for an enhanced civil penalty for serious bodily injury as per H&S 1569.49(f). The total civil penalty has been set at $10,000 for serious bodily injury. During the meeting Technical Support Program (TSP) was offered to the administrator. At this time the Department will follow up in a later date to see if the facility wants to participate in the program. An exit interview was conducted with Antonia Dionisio, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Allegation investigated: Facility failed to care for resident with restricted health condition. Staff forged resident's signature.

On October 19, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegations mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff members #1 (S1) and Resident members #2 to #5 (R2-R5) and Witness #1-Witness #2 (W1-W2) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), (R1's) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24), Los Angeles County Sheriff's Department Incident Report (dated 03/09/25) and Harbor UCLA Medical Records Medical Records (dated 03/25/25) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #2: Facility failed to care for resident with restricted health condition. It is alleged that the facility failed to provide appropriate care for Resident #1 (R1) due to a specific health condition. Reports indicate that (R1) required catheter care, but the staff did not maintain the catheter properly, and the area was not kept clean. As a result, (R1) endured catheter associated urinary tract infections (UTIs) every month. No further details regarding this matter were provided. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 through Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support the claim. (R2-R5) reported that they have no health restrictions classified as a "restricted health condition" and expressed no concerns regarding the care and supervision provided by the staff at this facility. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). During the interview, (S1) admitted that (R1) required catheter care and was under hospice services at the time of admission. Later, (R1) received assistance from home health services for catheter care as well. (S1) claimed that (R1) would also receive catheter maintenance during visits from the primary physician. However, despite (S1)'s assertions that hospice or home health was assisting with catheter care, no documentation was provided as evidence. (S1) acknowledged that this is a restricted health condition but failed to notify Community Care Licensing and did not have a care plan in place to address the restricted health condition. On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) confirmed that (R1) uses a catheter. (R1) stated that the facility staff provided care by transporting (R1) to Veterans Affairs (VA) for a catheter change. However, when asked how often (R1) see the primary physician, (R1) replied, “I never see him.” (R1) also confirmed to have never received any visits from the primary physician while at Harmony Home Care, nor have (R1) been seen by a Hospice Nurse or Home Health Nurse. The Department reviewed Harbor UCLA Medical Records (dated 03/25/25), (dated 10/03/23), (dated 10/11/23), (dated 11/24/23), and (dated 12/14/24), which revealed that (R1) suffered from repeated urinary tract infections due to the use of an indwelling urinary catheter. A catheter should only be used if ordered by a doctor and included in a care plan that outlines skilled catheter care and proper staff training. (Evaluation Report continues LIC 9099-C) In this instance, there was no evidence that these requirements were met. The absence of a catheter care plan led to the resident's recurrent infections. Further review of Los Angeles County Sheriff Department Incident Report (dated 03/09/25) revealed Staff #3 (S3), responsible for primary care for (R1), stated that (S3) is not a skilled nurse for catheter and wound care treatments. Staff #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. ALLEGATION #4: Staff forged resident's signature. It is alleged that facility staff forged the signature of Resident #1 (R1). Reports indicate that facility staff admitted to having forged (R1's) initials on the facility's admission agreement contract. No further details were provided in reference to this matter. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) recalled being informed about all the legal documents signed during their admission. None of the residents noticed any inconsistencies or unauthorized reproductions of their handwriting or signatures in the records. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). During the interview, (S1) admitted to signing a portion of the admission agreement for Resident #1 (R1). (R1) had missed some initials on a few sections of the document. (S1) claimed that this action was taken with (R1's) completed authorization and in (R1's) presence. (S1) stated that (R1) did not want to complete the rest of the document signing. Still, it was necessary to do so for licensing purposes to maintain complete compliance. On April 17, 2025, between 3:00 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) was presented with a copy of Harmony Home Care's admissions agreement, (R1) expressed concerns about the signature and initials, stating they did not appear to be (R1’s). (R1) speculated that it might be (R1’s) Power of Attorney (POA), might have made the signature. However, (R1) clarified that (R1) did not have a POA upon entering the facility on June 08, 2023. (Evaluation Report continues LIC 9099-C) A review of the Los Angeles County Sheriff Department Incident Report (dated 03/09/25), indicates in a statement from (S1) to have admitted having signed a portion of the (R1’s) contract in a few sections. Staff #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099 D). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #3: Staff did not provide timely medical information to authorized representative. It is alleged that facility staff failed to provide timely medical information to the authorized representative. It is reported that the facility staff failed to provide a copy of (R1’s) medical information, the “Admission Agreement,” to the authorized representative. No further details regarding this matter have been provided. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) reported no issues with staff providing medical or admission agreements to their authorized representatives, and they received them promptly. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed Staff #1 (S1). (S1) explained (R1) was self-responsible when (R1) was admitted on June 08, 2023. (R1) was responsible for all healthcare matters and contracts until a legal authorized representative to represent (R1). (R1) did not have an authorized representative with Power of Attorney for Health Care. As a result, the authorized representative was unable to obtain a copy of (R1's) contracts or medical records until they presented the necessary legal documentation. According to (S1), this issue was resolved when (R1's) authorized representative requested a copy of the "Admission Agreement" on March 10, 2025, and provided the required legal documentation as proof. On April 17, 2025, between 3:00 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) has confirmed that (R1) was responsible upon being admitted to Harmony Home Care. However, (R1) does not remember when (R1) consented to the Power of Attorney for Health Care. Nevertheless, (R1) acknowledges that an authorized representative is acting as the Power of Attorney (POA) for (R1). However, the POA did not have authorization to legally access (R1's) medical information or contracts while (R1) was still capable of making decisions according to (R1). The Department reviewed the Identification and Emergency Information LIC 601 (dated 08/08/24) revealed (R1) was responsible for financial, care, and legal issues. Further review of VA Durable Power of Attorney for Health Care and Living Will (signed 07/07/23) verified the primary POA for Health Care. However, the Signature and Seal of Notary Public was not notarized to make it legally binding outside VA Healthcare setting. Upon further review of the written communication between (S1) and (POA), (dated 03/10/25), it was confirmed that (R1's) Admission Agreement had been provided. (Evaluation Report continues LIC 9099-C) Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. ALLEGATION #5: Staff did not communicate with resident's authorized representative. It is alleged that the facility staff did not provide timely medical information for Resident #1 (R1) to the authorized representative. Reports indicate that on March 2, 2025, Staff #3 (S3) failed to contact the appropriate authorized representative when (R1) was lethargic for several days and required hospital medical attention. Instead, another representative was notified. No further details regarding this matter have been provided. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 through Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to validate this claim. (R2-R5) reported to have no issues or concerns with this matter. All residents reported that the facility staff adheres to proper call procedures and will promptly notify the authorized representatives of any changes in condition or hospitalization. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) claim this accusation is false. (S1-S2) stated they follow the proper notification procedures and will promptly advise the authorized representatives of any changes in condition or hospitalization. (S1) reported that (R1) when admitted was self-responsible and did not have an authorized representative as power of attorney for health care. (R1) was the one who contacted 911 on March 2, 2025, without the staff awareness and the authorized representative was contacted by Staff #3 (S3). When the primary authorized representative is not available, then the secondary authorized representative is contacted. On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). On March 2, 2025, (R1) recalled making the call to 911. (R1) preferred not to involve the authorized representative and understood that the staff would contact the primary representative. Instead, (R1) requested that the secondary representative be notified, allowing (R1) to take action to avoid the problem. (Evaluation Report continues LIC 9099-C) On October 19, 2025, between 11:14 AM and 11:25 AM, the Department interviewed Witness # 2 (W2). (W2) confirmed (S1’s) statement that the facility staff contacted the primary authorized representative and was unavailable. Additionally, (W2) validated that (R1) prefers to inform (W2) about healthcare matters. (W2) specified that the facility did not commit any injustice by continuing with its processes; ultimately, a representative was notified. The Department reviewed Los Angeles County Sheriff Department Incident Report (dated 03/09/25), and Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24) revealed (R1) had no mental condition that would limit the ability to make decisions for health matters. The Identification and Emergency Information LIC 601 (dated 08/08/24) revealed (R1) was responsible for financial, care, and legal issues. Further review of Durable Power of Attorney for Health Care and Living Will (signed 07/07/23) verified the primary POA for Health Care. However, the Signature and Seal of Notary Public was not notarized to make it legally binding outside VA Healthcare setting. Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation are Unsubstantiated.the state’s words, verbatim · CDSS document, Oct 19, 2025 · control 11-AS-20250310121815

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Nov 2, 2025

87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative...no later than seven days following admission... This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee admitted having falsified (R1’s) Admission Agreement by illegally signing another person's name or initials on the legal contract. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2025

Plan of correction: Licensee/Administrator shall review Tittle 22 87507 Admissions Agreement and submit in written statement have reviewed and will comply with the regulation requirements. The plan must be submitted by POC date 11/02/25 to ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87623(a)(1-2)(B) · Plan of correction due date: Oct 19, 2025

87623 Indwelling Urinary Catheter (a) The licensee shall be permitted to accept or retain a resident...requires the use of an indwelling catheter.. (1) Ensuring that insertion and irrigation of the catheter shall be performed by an appropriately skilled professional. (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional... (B) There shall be written documentation by an appropriately skilled professional outlining the instruction... procedures delegated... This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee failed to provide as evidence a catheter care was performed by a skilled professional nor provided an outlining instruction of procedures in a written care plan. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2025

Plan of correction: Licensee/Administrator shall review Tittle 22 87623 Indwelling Urinary Catheter and submit in written statement have reviewed and will comply with the regulation requirements. The plan must be submitted by POC date 11/02/25 to ernand.dabuet@dss.ca.gov

Allegation investigated: Facility retained resident with prohibited health condition.

On October 07, 2025, the Community Care Licensing (CCL) Licensing Program Analysts (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Administrator Antonia Dionisio greeted the LPA, who explained that the visit was to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff members #1 (S1) and Resident members #2 to #5 (R2-R5) and Witness #1 (W1) . The Department reviewed several documents, including the Resident Registered Roster LIC 9020 (dated 03/11/25), the Personnel Report (dated 12/16/22), (R1's) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24), Los Angeles County Sheriff's Department Incident Report (dated 03/09/25) and Harbor UCLA Medical Records Medical Records (dated 03/25/25) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #7: Staff dispensed wrong medication not prescribed to resident. It is alleged that the facility staff administered incorrect medications that were not prescribed for Resident #1 (R1). Reports indicate that medications intended for other residents were given to (R1) when (R1's) prescriptions were not refilled. The specific dates and types of medicines involved have not been provided. No further details are available regarding this matter. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to validate this claim. (R2-R4) expressed that the staff closely observes the medications for each resident. They have never received incorrect medications or experienced issues with refills. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) claim this accusation is false. (S1-S2) claimed to follow the Seven Rights of Medication Administration to ensure safe and effective medication delivery to prevent medication errors and protect residents' safety. (S1) indicated that (R1) is alert and can recognize the medications given to (R1) by the staff. (R1) is also able to administer (R1's) meds and store their own medications as ordered by (R1's) physician. On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) communicated a clear understanding of (R1's) medication needs, stating that while (R1) may not be familiar with the specific types of medications being dispensed, (R1) is committed to taking only those prescribed by (R1's) doctor. Moreover, (R1) expressed independence by indicating (R1's) ability to manage and store (R1's) own medications. However, (R1) emphasized a preference for staff assistance with this task. The Department reviewed (R1’s) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24). The Department confirmed that (R1) can administer and store its own prescription medications, with staff assistance provided as needed. (Evaluation Report continues LIC 9099-C) Additional review of (R1’s) Centrally Stored Medication and Destruction Record and Medication Administration Record (dated 01/01/25 through 03/10/25) confirmed the accuracy and compliance of (R1’s) medications, revealing no omission, errors or discrepancies. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. ALLEGATION #8: Staff did not provide nutritious snacks for residents. It is alleged that the facility staff does not provide nutritious snacks for Resident # (R1). Reports indicate that staff gave (R1) large bags of M&M’s, despite knowing that (R1) is diabetic, and there is no monitoring of (R1’s) intake of sweets. No further details regarding this matter have been provided. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to support this claim. (R2-R4) expressed that the staff monitors their meal and snack intake and have no concerns regarding the meals or snacks provided. They mentioned that the variety of meals and snacks is sufficient and meets nutritional standards. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff cannot valid this claim. Residents are provided with three meals and two snacks daily, all of which have nutritional value, according to (S1). (R1) receives diabetic-friendly meals and snacks that include high fiber, lean proteins, healthy fats, and controlled portion sizes. (R1's) snacks consist of cottage cheese, yogurt, energy bars, fruits, and vegetables. Additionally, (R1) occasionally brings personal snacks, which may include dark chocolate and sugary candies. These personal snacks are monitored by staff when notified that (R1) has brought treats. On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) stated that the facility staff consistently provided adequate meals and snacks that met essential nutritional standards. Additionally, (R1) expressed a clear preference for (R1's) personal snacks over those offered by the staff, indicating that this choice was based on individual taste. On March 11, 2025, and September 26, 2025, the Department conducted inspections of the food supply. The inspections revealed a variety of proteins, vegetables, fruits, whole grains, and other items, including bread, dairy products, eggs, and cereal. (Evaluation Report continues LIC 9099-C) Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of these allegations. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with the administrator Antonia Dionisio, and copies of the reports were provided. Ample non-perishable food supplies were available to last for at least one week, while perishable items were sufficient for a minimum of two days, in accordance with Title 22 regulations. Further reviewed of (R1’s) Physician’s Report LIC 602A (dated 05/24/23) and Preplacement Appraisal Information LIC 603 (dated 08/08/24) revealed (R1) was not on any special diet or observation of food intake. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. ALLEGATION #9: Staff inappropriately touched the residents. It is alleged that a staff member at the facility inappropriately touched Resident #1 (R1). During shower assistance, it was reported that staff made improper contact with (R1) in the genital area, which caused (R1) to feel disturbed about the incident. No further details regarding this matter have been provided. On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to confirm this claim. (R2-R4) stated that the staff are professional and have not committed any improper conduct towards any of the residents. On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff cannot support this accusation. (S1-S2) asserted that all residents are treated with dignity and respect. They emphasized that residents receive professional assistance with bathing. (S1) claimed that the accusation is fabricated, noting that Resident #1 (R1) is not assisted with baths or showers, but only receives assistance with sponge baths. On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) stated that (R1) felt the staff at Harmony did not mistreat (R1) and was treated with respect. (R1) denied being a victim of physical or sexual abuse by any staff members. (R1) emphasized that there were no inappropriate interactions, as (R1) had established clear boundaries. Additionally, (R1) mentioned that the staff provided sponge baths instead of showers as (R1's) preference, and (R1) felt comfortable with the level of care provided. A review of the Los Angeles County Sheriff Department Incident Report (dated 03/09/25), indicates that (R1) stated staff assisted with (R1’s) incontinence needs and confirmed that staff have not engaged in any inappropriate behavior towards (R1). (Evaluation Report continues LIC 9099-C) This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Edward Hector. As part of the investigation, Investigator Hector subpoenaed records from Harbor UCLA Medical and the Los Angeles County Sheriff's Department. The relevant records included the following: the Harbor UCLA Medical Records (dated 03/25/25), and the Los Angeles County Sheriff's Department Incident Report (dated 03/09/25). Additionally, Hector reviewed (R1's) Physician's Report LIC 602 (dated 05/24/23), Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24) as well as the Centrally Stored Medication and Destruction Record and the Medication Administration Record covering the period from 01/01/25, to 03/10/25. Furthermore, the investigator conducted interviews with Staff #1(S1), Witness #1 (W1), and Resident #1 (R1). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #1: Facility retained resident with prohibited health condition. It is alleged that Resident #1 (R1) developed pressure injuries as a result of staff neglect. Reports indicate that (R1) developed stage 3 bedsores in the groin and buttocks area, which the facility failed to report or treat. Additionally, home health or hospice care services were not provided. No further details concerning this matter were available. On March 2 and March 4, 2025, Resident #1 (R1) was admitted to Harbor-UCLA Medical Center due to abnormal labs and general weakness. Medical records revealed that a wound assessment was conducted, which showed a stage 3 pressure injury in the sacral/coccygeal area and another on the right hip ischium. The sacral/coccygeal wound measured 5 cm by 7 cm, while the pressure injury on the right ischium measured 3 cm by 10 cm. On April 17, 2025, at 2:30 PM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Harmony Home for approximately 1.5 to 2 years. (R1) expressed experiencing bedsores in the buttocks area and mentioned having difficulty lying on the backside for extended periods due to these pressure injuries. (R1) indicated that no facility staff assisted with repositioning every two hours, and help was only provided when explicitly requested. Additionally, (R1) noted that while the facility applied some form of medication to the wounds, it was not done effectively. Furthermore, (R1) confirmed that no skilled nurse, hospice nurse, or home health nurse had come to address the pressure injuries. (Evaluation Report continues LIC 9099-C) On April 17, 2025, at 3:35 p.m., the Department interviewed Witness #1 (W1). (W1) reported observing facility staff applying cream and gauze to (R1's) buttocks. (W1) confirmed that (R1) did not receive any home health, hospice, or skilled nursing visits while residing at Harmony Home Care. Additionally, (W1) mentioned that (R1) had not received home health visits for a year before changing insurance carriers. On April 17, 2025, at 5:01 p.m., the Department interviewed Staff #1 (S1), the facility administrator of Harmony Home Care. (S1) is responsible for training the staff to spot pressure injuries. (S1) instructs the staff to look for signs, such as redness or blisters, on the skin before an open wound. If staff see these symptoms, they must inform the administrator. The administrator will then contact the primary physician and family representatives to obtain a referral for home health or hospice services. (S1) stated that the staff are trained to reposition residents every two to three hours. However, (S1) also mentioned that the staff do not get help with wound care. Additionally, (S1) noted that (R1) was receiving nursing visits to evaluate pressure injuries when admitted. (S1) revealed that (R1) has had ongoing pressure injuries "on and off" since being admitted to the facility. (S1) claimed that (W1) canceled hospice services in September 2023. (S1) claims to have asked several times about reinstating (R1's) home health visits or transferring (R1) to another facility, but (W1) refused both options. (R1) has not received any hospice or home health visits, and no doctor or skilled nurse has visited in the past 30 days. (S1) claimed that (R1) refused to let the facility staff reposition (R1) regularly to relieve pressure from the wounds. Additionally, (S1) could not provide any documentation of hospice records, incident reports, or wound care related to (R1's) pressure injuries. As a result, (R1) continues to experience pressure injuries due to poor circulation, having been bed-bound since admission. The Department reviewed the following records: Harbor UCLA Medical Records (dated 03/25/25), Los Angeles County Sheriff Department Incident Report (dated 03/09/25), Windsor Convalescent Center Medical Records (dated 11/21/24), and Harbor UCLA Medical Records (dated 12/14/24). Notably, (R1) was assessed for Stage 3 pressure injuries. Further review of facility's written communications (dated 10/03/23) revealed (R1) was removed from hospice care services effective September 29, 2023. Staff member #3 (S3) could not be interviewed due to (S3's) unavailability, as (S3) is no longer employed at the facility. Furthermore, (S3) did not provide any contact information, such as a phone number or forwarding address, which made it unattainable to reach out for further insights or comments about (S3's) awareness of this allegation. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 11-AS-20250310121815

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 8, 2025

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician. This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) history of pressure injuries and retained (R1) with a stage 3 prohibited health condition and failed to ensure proper care, such as hospice or home health care services, were provided for the wounds. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee/Administrator shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 10/08/25 to ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Oct 8, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) pressure injuries and retained (R1) with stage 3 wounds and failed to ensure proper care, such as hospice or home health care services, were not provided. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee/Administrator will review Title 22, Section 87615, of the regulation and submit a written review to ensure compliance with the regulations. Licensee will retrain staff on pressure injuries and submit completed training with staff name, and dated completed by POC date 10/08/25 to ernand.dabuet@dss.ca.gov

Type of visit: Required - 1 Year

On September 26, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. 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. Currently, the facility has (1) hospice resident in care. The facility is approved for (1) hospice resident. 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 emergency fire drills on a monthly basis. The last Fire Drill was on 09/05/25. A review of the Medication Administration Record (MAR) was observed to be maintained in order. (Evaluation Report continues LIC 809-C) 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 with a zero balance. An audit of residents #1-#3 (R1-R3) service files and staff #1-#2 (S1-S2) personnel files. The facility has the current administrator's certification on file for Antonia Dionisio #7009828740 Expiration 12/11/2026. DEFICIENCIES: Resident #3 admitted without a Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A) on file. Resident #1 diagnosed with NCD has a Physician Report LIC 602A from 2023. No current Medical Assessment for Residential Care Facilities for the Elderly LIC 602A on file. LPA observed staff prescription medications left unattended and accessible to residents in care in a vacant resident's room. LPA observed Resident #3 had full bed rails and is not on hospice nor had physician's orders for full bed rails. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-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. *the state’s words, verbatim · CDSS document, Sep 26, 2025

Allegation investigated: Facility did not safeguard resident’s belongings.

On 4/9/2025, at 8:32 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Susan Parungao-Caregiver who was informed of the purpose of the visit. The investigation consisted of the following: On 4/3/2025 at 2:45 PM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medication list, appraisal, needs and services plan, physicians report, admissions agreement with personal property valuables list, and staff and client roster. LPA Allen conducted interviews with Staff 1- Staff 2 (S1 - S2), Residents 1- resident 3 (R1 -R3). Continued Unsubstantiated Investigation revealed the following: Allegation: Facility did not safeguard resident’s belongings On 4/3/2025 LPA interviewed Staff 1- Staff 2 (S1 - S2), 2 out of 2 staff members stated that R1’s personal belongings were safeguarded and not stolen by anyone. They also confirmed that R1’s personal items had been picked up and accounted for by an outside party. On 4/7/2025 at 11:58 AM, LPA Allen interviewed R1, who stated they were not unaware of their personal belongings being stolen by any staff. R1 affirmed that all their possessions were in their care and emphasized that no items had ever been stolen by staff members. During the interview LPA Allen asked about specific items that were allegedly missing, and Resident 1 (R1) stated all their items were accounted for. Additionally, LPA Allen reviewed R1’s personal property and valuables log and appeared to be up to date. LPA also attempted to interview resident 2 (R2) who was not willing to be interviewed and resident 3 (R3) stated their personal belongings have not been stolen by staff. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Antonia Dionsio- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 11-AS-20250326171613

Type of visit: Case Management - Deficiencies

On March 11, 2025, at 9:25 AM, Licensing Program Analysts (LPAs) Ernand Dabuet and Jose Anguiano conducted an unannounced case management visit to the facility in connection with complaint #11-AS-20250310121815. The LPAs met with the administrator, Antonia Dionisio, and explained the purpose of their visit. During the visit, the LPAs reviewed the facility's Personnel Report (05/16/22) and found that Staff #3 was not listed in the California Department of Social Services Community Care Licensing Information System (LIS 531) or Guardian. Staff #3 did not obtain a Criminal Record Clearance 873559(e)(1) before working, residing, or volunteering in the licensed facility. As per regulations, all individuals must undergo a criminal record clearance. The administrator confirmed that Staff #3 did not have a Criminal Record Clearance prior to employment at the facility. Civil penalties were assessed, and an exit interview was conducted. The licensee was provided with a copy of their appeal rights, and their signature on this form acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 8733559(e)(1) · Plan of correction due date: Mar 12, 2025

87355 Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on record review and interview, there's evidence Staff #3 is did not have Criminal Record Clearance prior to working at the facility. This violation which is an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Licensee will ensure to adhere to Title 22 Reg. 873449 have all staff prior to working in a licensed faciltiy have been Criminal Record Clearance. Licensee will have staff #3 fingerprint clearance by POC 03/12/25. IMMEDICATE CIVIL PENALTIES

Type of visit: Required - 1 Year

On 08/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Elmer Carlos. LPA explained the purpose of today’s visit. Carlos contacted the administrator Antonia Dionisio who later was present during the visit. The facility is licensed to operate for (6) non-ambulatory of which (2) maybe bedridden elderly adults ages 60 and above. Currently, the facility has (1) hospice resident in care. The facility is approved for (1) hospice resident. 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 107.8 degrees F. A comfortable temperature of 78 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 emergency fire drills on a month basis. The last Fire Drill was on 07/05/24 10:40 am. A review of the Medication Administration Record (MAR) was observed to be maintained in order. (Evaluation Report continues LIC 809-C) 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 09/23/23 through 09/23/24. The facility has CCLD license annual due on 08/11/24. An audit of residents #1-#4 (R1-R4) service files and staff #1-#4 (S1-S4) personnel files. The facility has the current administrator's certification on file for Antonia Dionisio #6033374740 Expiration 12/11/2024. DEFICIENCIES: Resident #2 who was admitted in June 2023 had missing needs/services appraisal and incomplete CCLD forms fill out completely. Observation of window screen for room #5 has a hole and will need to repair/replace. Observation of no shower curtain in resident's bathroom for privacy. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-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. *the state’s words, verbatim · CDSS document, Aug 8, 2024