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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200013
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:30:38 PM

Document Has Been Signed on 01/30/2024 03:30 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:HUYNH, BRENDAFACILITY TYPE:
735
ADDRESS:34213 ARIZONA STTELEPHONE:
(510) 396-0850
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Brenda HuynhTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management - incident visit and met with Administrator Brenda Huynh. LPA explained to the Administrator the purpose of the visit.

Based on records review, C1 is independent in most ADLs. C1 is verbal and ambulatory. C1 needs to be on catheter temporarily due to the incident that happened on 1/27/24. The Administrator states the catheter will be removed on Monday, February 5, 2024. The Administrator states C1 has an appointment with the Psychiatrist on February 12, 2024 to review medications and address the incident.

While at the facility, LPA interviewed C1. C1 states that C1 is doing fine and everything is good.

The Administrator will update LPA on the outcome of C1's appointment with the Psychiatrist. Administrator will meet with behaviorist and send LPA a copy of an updated behavior plan.

There is no deficiency noted for this visit.

A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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