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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601494
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:33:45 PM


Document Has Been Signed on 05/23/2024 01:33 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
E BAY DELTA AC/SC, 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:
05/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Vincent Catequista, CaregiverTIME COMPLETED:
12:40 PM
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On 05/23/2024 at 11:55 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Caregiver, Vincent Catequist, and informed the reason for visit. Vincent phoned the Licensee/Administrator, Restituto "Resty" Sabadera to inform. LPA spoke with the Administrator and advised that LPA was there to tour the facility.

On 04/17/2024, LPA conducted an Annual visit in which deficiencies were cited. The POC due date was 4/18/2024 for Type A deficiencies and for the Type B deficiencies the POC due date was 5/15/2024.

LPA toured the back yards and observed a toilet camode, bricks, wheel barrow, wire, ladders, boxes covered with a tarp and other clutter in the back behind the shed. Licensee/Administrator Resty stated that those items is their personal items from their Sacramento home.

Facility has the following deficiencies that was not cleared:

87303(a) = 8 Days x $100.00 = $800.00

Civil Penalties in the total amount of $800.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights, and LIC421FC provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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