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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200013
Report Date: 08/17/2022
Date Signed: 08/17/2022 11:14:27 AM

Document Has Been Signed on 08/17/2022 11:14 AM - 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:LIAHONA COMMUNITY CAREFACILITY NUMBER:
019200013
ADMINISTRATOR:TABION, RODERICK BFACILITY TYPE:
735
ADDRESS:34213 ARIZONA STTELEPHONE:
(510) 396-0850
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Roderick Tabion, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 8/17/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with administrator, Roderick Tabion. Licensee, Reylita Tabion arrived an hour and a half later.

Upon entry, staff did not conduct screening for LPA. LPA observed hand sanitizer at screening station along with visitor's log. LPA toured facility including but not limited to client's bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette, social distancing, and signs & symptoms posted in common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at bathrooms.

During record review, LPA observed visitors log and temperature log for clients. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food supplies, and paper supplies are sufficient.

At 9:00AM, LPA observed broken shower door in the master bathroom. Staff fixed the shower door during inspection. LPA observed C1 and C2 has broken window screens. Refrigerator's light bulb was out.

At 9:10AM, LPA observed unlocked laundry detergent and unlocked cleaning supplies cabinet. LPA observed unlocked gardening tools in the backyard. Staff lock up the gardening tool, cleaning ,and detergent during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 08/17/2022 11:14 AM - It Cannot Be Edited


Created By: Grace Luk On 08/17/2022 at 10:33 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LIAHONA COMMUNITY CARE
FACILITY NUMBER: 019200013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having unlocked laundry detergents and cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Staff locked up the laundry detergent, cleaning supplies, and gardening tools during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/17/2022 11:14 AM - It Cannot Be Edited


Created By: Grace Luk On 08/17/2022 at 10:33 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LIAHONA COMMUNITY CARE
FACILITY NUMBER: 019200013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having broken shower door in master bathroom, broken window screens, and broken refrigerator light bulb which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Staff fixed the shower door during inspection. Administrator has agreed to fix the broken screens in C1 and C2's rooms, and put in a new light bulb in the refrigerator. Administrator will send picture proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7