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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 01:43:46 PM


Document Has Been Signed on 05/23/2024 01:43 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Vincent Catequista, CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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On 05/23/2024 at 12:40 PM, Licensing Program Analysts (LPAs) Lori Alexander conducted an unannounced to conduct a case management visit. LPA met with Caregiver, Vincent Catequista. Vincent phoned Licensee/Administrator, Restituto "Resty" Sabadera.

While LPA was at the facility for another visit, the following deficiencies was observed.

At 11:59 AM, LPA observed an latch lock located on the front door at the bottom of the front door. LPA discussed this lock latch on 04/17/2024 with Resty when leaving. LPA observed the lock when leaving the facility. Resty stated that he would remove the lock on 04/17/2024.

At 12:15 PM, LPA observed scissors sitting on the kitchen counter, tablet medications, Omeprazole tablets unlocked laying on dining room table, insulin, inhalers, bottle Mucus Relief cough liquid sitting on counter unlocked.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report, appeal rights, and LIC421FC and LIC421IM 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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Document Has Been Signed on 05/23/2024 01:43 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
E BAY DELTA AC/SC, 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: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/24/2024
Section Cited
CCR
87468.1

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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

This requirement is not met as evidenced by:


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Administrator removed the latch lock during the visit. Deficiency cleared.
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Based on observation, the licensee did not comply with the section cited above in by having a latch lock on front bottom door which poses a potential health, safety or personal rights risk to persons in care.
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Type A
05/24/2024
Section Cited
CCR87465(h)(2)

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87465 (h)(2) Incidental Medical and Dental Care
(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:
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Administrator removed the medications. Deficiency cleared during visit.
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Based on observation, the licensee did not comply with the section cited above in by not having bottled medications, tablet medications and insulin inaccessible to clients which poses an immediate health and safety risk to persons in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2