197607821-1-9-2024-31-AS-GSAO-CZBTEW-20240109134038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607821
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:40:46 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/09/2024 01:40 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ZION RESIDENTIAL CARE		FACILITY NUMBER:	197607821
ADMINISTRATOR:	JENNETH AGUILAR		FACILITY TYPE:	740
ADDRESS:	16654 SAN FERNANDO MISSION BLV		TELEPHONE:	(818) 620-2202
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Jenneth Aguilar		TIME COMPLETED:	02:05 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 01/09/24, at 11:50 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Evelyn Bautista. Jennet Aguilar the administrator was called and later arrived. LPA asked for the census, resident, and staff rosters. The caregiver stated there is no residents at the facility. LPA asked the caregiver what the reason was for no residents being at the facility and the caregiver stated, “they are in the hospital.” The administrator confirmed that the residents never returned from hospital. The administrator also stated, “I emailed the licensee department to let them know, I haven’t had anyone for over six (6) months. The facility has been licensed as a Residential Care Facility for the Elderly. The physical plant was toured inside and outside at 12:15 p.m. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets on your right-hand side. The medication cart is kept in the kitchen area locked and secured. There is one washer and dryer kept in the kitchen area. The fire extinguisher was observed to be full and dated March 2023. LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ZION RESIDENTIAL CARE	FACILITY NUMBER: 197607821
	VISIT DATE: 01/09/2024

NARRATIVE

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Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The dining room area has six (6) seats for residents and a television. The living room area has proper seating and a television. The facility temperature is at 70 degrees Fahrenheit.

No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were tested and operational. The facility has a current telephone landline and internet access.

Bedrooms: Facility has six (6) bedrooms and were toured. The bedrooms are fully furnished with proper lighting and bedding. Four (4) of the bedrooms are single, occupancy. One (1) of the bedrooms can be used as a shared and has a private bathroom. There is one (1) staff bedroom currently occupied by staff. There is another bathroom for staff and residents use. There are two (2) cabinets that have extra linen, PPE’s and incontinence. The bathrooms had proper grab bars, non-skid mats. Bathroom contained a trash can with tight-fitting lid. Hot water was tested and measured within regulations.

Outside/Backyard: The toxins are kept in a storage shed outside locked and secured. The garage is detached from the house with an extra refrigerator. The outside/backyard has furniture for residents to have proper seating. The facility has no signal system.

Administrative: There is no annual fee that is due right now. The Insurance plan is updated, disaster plan, Resident Rights, licensee certificate, Infection control, Ombudsman, and Facility Sketch are against the wall at the entrance of the facility.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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