019200013-5-16-2024-15-AS-LFOA-D5BURY-20240516154931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200013
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:49:41 PM

Document Has Been Signed on 05/16/2024 03:49 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 CARE		FACILITY NUMBER:	019200013
ADMINISTRATOR:	HUYNH, BRENDA		FACILITY TYPE:	735
ADDRESS:	34213 ARIZONA ST		TELEPHONE:	(510) 396-0850
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Brenda Huynh		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 John Mendiola. LPA explained to Mendiola the purpose of visit. The Administrator Brenda Huynh arrived at the facility at around 12:45 pm 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 one client getting ready for work and one staff. LPA inspected the facility inside and out including but not limited to 4 client bedrooms, bathroom, kitchen, dining area, garage and backyard. There was no body of water observed. At around 12:35 pm, hot water in the kitchen was measured at 140.5 Fahrenheit. At 12:45pm, LPA observed the following: 1. broken hamper in the backyard 2. side exit gate was observed with a sliding bolt at the bottom 3. screen door by the dining area ripped 4. window shutters in Room 5 dusty 5. blinds in Room 2 broken Fire extinguisher in the kitchen was observed full and last inspected on 7/9/2023. Carbon monoxide and smoke detector were tested and observed functional. There was sufficient supply of perishable and non perishable foods observed. Refrigerator temperature was at 45 Fahrenheit and freezer was at 0 Fahrenheit Medications were observed locked in a cabinet in the hallway. There was sufficient supply of towels, sheets and warm blankets observed. continuation on Lic 809D

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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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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: 05/16/2024

NARRATIVE

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At 1 PM, LPA reviewed P & I money and log with the Administrator. The facility has surety bond sufficient to cover amount of cash being handled. At 1:25 PM, LPA reviewed 5 resident files and 4 staff files. All staff are fingerprint cleared and associated to the facility. They have current First aid and CPR training. The last fire drill was conducted on April 10, 2024.

At 3 PM , LPA reviewed Medication Administration Record (MAR) and medications with Administrator.

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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2024 03:49 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having hot water at 140 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Administrator will adjust hot water within range and submit self certification stating temperature is within range.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/16/2024 03:49 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having ripped screen door, ripped screen window, bucket/broken hampers, etc in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	The Administrator will ensure the backyard is free from objects, get screen door/window fixed and submitphoto proof to CCL by POC date.

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a bolt in the side gate exit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	The Administrator will remove the bolt and submit self certificatin that side gate will be made accessible all the time.

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	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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