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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601494
Report Date: 04/28/2022
Date Signed: 04/28/2022 06:32:00 PM


Document Has Been Signed on 04/28/2022 06:32 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:MT. ZION HOME FOR THE ELDERLYFACILITY NUMBER:
015601494
ADMINISTRATOR:SABADERA, RESTITUTOFACILITY TYPE:
740
ADDRESS:32655 ALMADEN BLVDTELEPHONE:
(510) 475-5622
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Gertrudes Sabadera, CaregiverTIME COMPLETED:
06:45 PM
NARRATIVE
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On 4/28/2022 at 1:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Gertrudes Sabadera, Caregiver and explained the purpose of the visit. Restituto Sabadera arrived at 1:30PM.

Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared residents' bathroom was measured at 115.2 degrees Fahrenheit. Fire extinguisher was last serviced on 11/22/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/5/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC9099C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494
VISIT DATE: 04/28/2022
NARRATIVE
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Continued from LIC9099.

-LIC610E Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiencies were observed:

-At 1:10PM, LPA observed two (2) bottles of medicine for Staff 2 (S2) and medication for Resident 4 (R4).
-At 1:15PM, LPA observed spider webs on light fixture in kitchen, crumbs and deceased insects on kitchen floor near patio door, unsanitary kitchen floor.
-At 1:20PM, LPA observed a can of raid, two (2) knives, and calcium pills sitting on kitchen counter. Kitchen drawer near sink containing knives was unlocked. Roach crawling on kitchen counter and kitchen floor. Gnats flying around kitchen area.
-At 1:25PM, LPA observed cabinet above counter unlocked containing medication.
-At 1:32PM, LPA observed refrigerator unsanitary. Medications in refrigerator accessible.
-At 1:37PM, LPA observed a gallon of Clorox and a gallon of disinfectant sitting near office. Office is located near front door.
-At 1:45PM, LPA observed Resident 1 (R1) and Resident 4 (R4) sharing bedroom #1. In the closet was R4's clothing.
-At 1:47PM, LPA observed women clothing hanging in bathroom that is located in bedroom #1. Uncleaned underwear in a plastic bowl sitting in sink. Administrator stated for owners only. A bedroom cannot be used as a passageway.
-At 1:57PM, LPA observed garbage cans with trash located on ramp leading into backyard from kitchen patio door. Three (3) shower chairs sitting, trash bags containing recyclables, and two (2) commodes sitting on left-hand side of house.
-At 2:25PM, LPA observed four (4) cans of expired can goods.

Continued on LIC9099C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494
VISIT DATE: 04/28/2022
NARRATIVE
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Continued from LIC9099C.

-At 2:50, LPA reviewed residents file and observed R1 and R2's file has not been completed. Both files are missing Admission agreement, appraisal needs and services plan, personal rights, identification and emergency contact, preplacement appraisal, physician's report and consent form for R1.
-At 3:45PM, LPA observed R1 in wheelchair with a Velcro restraint closed in back of wheelchair.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of person with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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 2 knives sitting on kitchen counter, drawer near kitchen sink unlocked containing knives. poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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2
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4
Administrator agreed to remove knives from counter and knives in unlocked drawer and make then inaccessible to residents. Administrator locked knives in kitchen cabinet underneath sink during inspection. Deficiency cleared.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of persons with dementia. (f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above in having a can of raid and calcium pills, stool softener sitting on kitchen counter, R4's medication sitting on dining room table, medicine in refrigerator accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Administrator agreed to remove items to make inaccessible to persons in care and submit a photo to CCLD by POC date. Administrator removed stool softener, raid, and calcium pills and made inaccessible to residents during inspection. Deficiency cleared.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 12


Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)
a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.
(A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
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 by having R1 sitting in wheelchair with restraint fastened behind wheelchair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Administrator agreed to remove restraint and submit request for an exception to CCLD by POC date. Restraint was removed 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 12


Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural support (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.
(A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in obtaining a doctor's order for R1 to have a restraint which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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Administrator agreed to obtain a doctor's order for R1 to have a restraint and submit a copy to CCLD by POC date.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 6 of 12


Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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 spider webs around facility, refrigerator clean and sanitary which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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Administrator agreed to remove spider webs around facility, clean refrigerator and submit photos to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(27)
87555 General Food and Service Requirements (b) The following food service requirements shall apply:
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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 gnats, flies, and roaches flying around kitchen, on kitchen counter and kitchen floor which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Administrator agreed to have a pest control service treat facility inside and submit a copy of the invoice to CCLD with completed visit by POC date.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 7 of 12


Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
87555 General Food and Service Requirements (b) The following food service requirement shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 in having expired can goods in the pantry which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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2
3
4
Administrator agreed to clean pantry and remove all expired can goods, and submit a photo of cleaned pantry to CCLD by POC date.
Type B
Section Cited
CCR
87307(a)(2)(C)
87307 Personal Accomendations and Services
a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in using bedroom #1 as a passageway to the bathroom located in bedroom #1 as a personal bathroom for Licensee which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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2
3
4
Administrator agreed to submit documentation stating that bathroom in bedroom #1 is to be used by Licensee only including facility sketch, and submit documentation and sketch to CCLD by POC date.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 8 of 12


Document Has Been Signed on 04/28/2022 06:32 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: MT. ZION HOME FOR THE ELDERLY
FACILITY NUMBER: 015601494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in have resident files for R1 and R2. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
1
2
3
4
Administrator agreed to put together and complete files for R1 and R2 and submit a copy of all documentation to CCLD by POC.
Type B
Section Cited
CCR
1569.269(a)(17)
1569.269 Enumerated rights; severability (a) Residents of residential care facilitties for the elderly shall have all of the following rights:
(17)To reasonable accommodation of resident preferences concerning room and roommate choices.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in having a male and female not married sleeping in same room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
1
2
3
4
Administrator agreed to submit statement of consent from Responsible party's of residents that room it is ok to be shared and submit to CCLD by POC date.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 9 of 12