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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601494
Report Date: 04/07/2023
Date Signed: 04/07/2023 05:00:29 PM


Document Has Been Signed on 04/07/2023 05:00 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: 2DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Restituto SabaderaTIME COMPLETED:
05:20 PM
NARRATIVE
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On 4/7/2023 at approximately 10:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection. LPA met with Administrator Restituto Sabadera and explained the purpose of visit.

LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, dining area, kitchen and backyard. Hot water measured at 118 F. There was sufficient supply of perishable and non perishable foods.

During the visit, LPA observed the following:

1. at approximately 10:40 am, LPA observed injection, eye drops and other medicines unlocked in the refrigerator
2. at approximately 10:46 am, LPA observed mold on the kitchen window sills, dirty walls
3. at approximately 10:50 am, LPA observed grease on stove top, microwave , walls and refrigerator
4. at approximately 10:52 am, LPA observed dust, crumbs and other things on the floor
5. at approximately 1pm while conducting file reviews, LPA observed staff does not have current proof of training
6. at approximately 1:30pm, LPA observed facility does not have current proof of disaster drill
7. at approximately 2:30pm, LPA observed unused equipment, empty boxes, chairs, tables etc in the backyard
8. at 4pm, LPA observed resident is being given vitamin without doctor's order

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 was conducted. Appeal Rights and a copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 04/07/2023 05:00 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food 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 by not maintaining a clean and safe kitchen area which poses an immediate health, safety or personal rights risk to persons in care. LPA observed mold on the kitchen window, grease on stove, microwave, kitchen walls.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator will clean kitchen area and notify LPA once clean up is completed. LPA will come back to conduct a POC visit.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 leaving insulin and eyedrops unlocked in the refregerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Administrator locked all medicines in the refrigerator during the visit. Deficiency is 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/07/2023 05:00 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 required disaster drill quarterly which poses/posed a potential health, safety or personal rights risk to persons in care. Last drill was conducted
POC Due Date: 04/14/2023
Plan of Correction
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By POC date, Administrator will submit to CCL proof of current disaster drill.
Type B
Section Cited
CCR
87470(a)(2)(A)


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 failing to maintain floor surfaces clean which poses/posed a potential health, safety or personal rights risk to persons in care. Floor surfaces were observed dusty, lots of crumbs and dirt.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator will clean floors throughout the facility and notify LPA once completed. LPA will conduct POC visit.
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/07/2023 05:00 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(B)


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 failing to maintain walls and windows clean and free from dust, cobwebs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator will clean walls and windows and notify LPA once completed. LPA will conduct a POC visit.
Type B
Section Cited
CCR
1569.696


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 failing to provide training to staff which poses/posed a potential health, safety or personal rights risk to persons in care. Last training was conducted in 2021.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator will conduct in-service with staff and submit proof to CCL 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/07/2023 05:00 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303


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. LPA observed unused equipments like shower chairs, commode, wheelchairs, empty boxes in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator will clean up back yard and notify LPA once completed. LPA will conduct POC visit.
Type B
Section Cited
CCR
87465(a)(5)(A)


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. Administrator was providing a resident vitamin (Areds) per instruction from the family but no doctor order and giving resident Senna not according to doctor's order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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By POC date, Administrator will obtain order from resident's doctor and submit a copy to CCL.
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5