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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609688
Report Date: 05/24/2023
Date Signed: 05/24/2023 01:15:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20230519114653
FACILITY NAME:ZION ETERNITY RESIDENTIALFACILITY NUMBER:
197609688
ADMINISTRATOR:KING, MARLONFACILITY TYPE:
735
ADDRESS:43642 DANA DRTELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Anderson MunozTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that Client 1 (C1) was not allowed back into the facility, after hospitalization because C1 was identified with a condition that the facility states they cannot care for. LPA met with the administrator, Anderson Munoz, and advised him of the complaint. At approximately 9:30am to 10:30am, LPA conducted interviews with staff. Between 10:30am and 11:30am, a record review conducted, followed by contact with Regional Center (RC) for additional information. A plant inspection was then made between 11:30am-12:30pm to insure the health and safety of the clients in care. According to the administrator, C1 was never evicted. Facility was notified by the hospital that C1 would require oxygen intake and C-Pap. Administrator would have taken C1 back, but prior to re-admission would be working in conjunction with Regional Center to assess C1 to insure they would be able to continue to meet C1's needs, as C1 is low functional, and this is a new condition that was not identified during the initial admission process. While in the middle of that assessment, RC was able to find placment at a skilled nursing,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20230519114653
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ZION ETERNITY RESIDENTIAL
FACILITY NUMBER: 197609688
VISIT DATE: 05/24/2023
NARRATIVE
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to accommodate C1's needs. Call made to RC, who confirmed that C1 was admitted to a skilled nursing to better fit their needs.

Based on the information obtained, there was insufficient evidence to prove that C1 was Unlawfully Evicted. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator advised and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2