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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200013
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:45:36 PM

Document Has Been Signed on 02/09/2024 04:45 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: 4DATE:
02/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Brenda HuynhTIME COMPLETED:
05:00 PM
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On this day at around 3:30pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management - incident visit and met with Administrator Brenda Huynh. LPA explained to the Administrator the purpose of the visit.

During the visit, LPA obtained and reviewed the following records for Client 1 (C1): IPP dated 2/5/2020, IPP Addendum dated 2/27/2023, Physician's Report dated 9/1/2023, Incident Report, Lic 500.

Based on record reviews conducted, C1 is ambulatory, feeds/bathes/dresses self. C1's Individual Program Plan (IPP) indicate C1 had no reported problems with chewing or swallowing. IPP also indicates C1 uses proper utensil and eats without spillage. C1 warms own lunch in the microwave when at the program. C1 eats pizza with bacon and pepperoni, chicken Parmesan and Chinese foods.

C1's IPP indicates that C1 eats dinner in C1's room. LPA did not observe any dietary restriction order for C1.
The Administrator states that there were 3 staff on duty on the day of the incident but did not hear any sound coming from C1's room. When S2 knocked on C1's room for the medication, there was no response which led S2 to going inside the room and found C1 unconscious. S2 initiated CPR immediately until paramedics arrived. S2 has First aid/CPR training which expires in November 15, 2024.

LPA requested a copy C1's death certificate and coroner's report.

There is no deficiency noted for this visit. LPA will review records including death certificate when available and will come back, if needed.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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