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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200013
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:27:10 PM

Document Has Been Signed on 06/06/2023 02:27 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
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: 5DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Roderick TabionTIME COMPLETED:
02:45 PM
NARRATIVE
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On this day at around 10:00 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct an annual required inspection. LPA was met by staff Roderick Tabion and explained the purpose of visit. Licensee Reylita Tabion and Administrator Brenda Huynh also arrived at the facility.

The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients.

Upon arrival, LPA observed 1 client waiting for pickup. LPA interviewed Client at around 10:10 am.
LPA inspected the facility inside and out including but not limited to 4 client bedrooms, bathroom, kitchen, dining area, garage and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. At around 10:15 am, hot water in the kitchen was measured at 122.6 F. At 10:17 am, LPA observed a bottle of chemical spray under the kitchen sink unlocked. At around 10:42 am, LPA observed multivitamins unlocked in a cabinet in the hallway.

Fire extinguisher in the kitchen was observed full and last inspected on 9/30/2022. Carbon monoxide and smoke detector were tested and observed functional. There was sufficient supply of perishable and non perishable foods observed. Refrigerator temperature was measured at 45 F and freezer temperature was at 0 degrees Fahrenheit. Medications were observed locked in a cabinet in the hallway. There was sufficient supply of towels, sheets and warm blankets observed.

Facility has an infection control plan. Facility has a surety bond in the amount of $5,000 which is sufficient to cover amount of money being handled at one time.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LIAHONA COMMUNITY CARE
FACILITY NUMBER: 019200013
VISIT DATE: 06/06/2023
NARRATIVE
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At 10:45 am, LPA reviewed P & I money and log. At 11:00 am, LPA reviewed 3 resident files, Administrator and 2 staff files.

At 1:30 pm, LPA reviewed Medication Administration Record (MAR) and medications with Administrator.

The following deficiencies were observed:
  • at 10:15 am, LPA observed hot water measured at 122.6 F in the kitchen sink
  • at 10:17 am, LPA observed a bottle of chemical spray under the sink unlocked
  • at 10:42 am, LPA observed multivitamins unlocked in a cabinet in the hallway
  • Last fire drill was conducted in 12/2022


Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Failure to correct deficiencies by due date may result to civil penalty.

Exit interview was conducted with Administrator. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2023 02:27 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/06/2023 at 01:35 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LIAHONA COMMUNITY CARE
FACILITY NUMBER: 019200013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023

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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Based on observation, the licensee did not comply with the section cited above in having cleaning chemical and multivitamins unlocked and accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Administrator locked chemical and multivitamins during the visit.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 122.6 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Administrator adjusted hot water temperature to 115 F during inspection.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2023 02:27 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/06/2023 at 01:35 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LIAHONA COMMUNITY CARE
FACILITY NUMBER: 019200013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not conducting emergency drill every quarter which poses/posed a potential health, safety or personal rights risk to persons in care. Last earthquake drill was done on 12/2021 and last emergency drill on 12/2022.
POC Due Date: 06/13/2023
Plan of Correction
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Administrator will conduct emergency drills and submit proof of training to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
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