197609688-9-29-2023-31-AS-EMIR-DAHPNC-20241029112742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609688
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:05:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
09/19/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230919081545

FACILITY NAME:	ZION ETERNITY RESIDENTIAL		FACILITY NUMBER:	197609688
ADMINISTRATOR:	KING, MARLON		FACILITY TYPE:	735
ADDRESS:	43642 DANA DR		TELEPHONE:	(818) 687-3830
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jhomer Yuson- Back Up Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide proper medication assistance to client in care
Staff did not treat client in care with dignity and respect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/29/23 Licensing Program Analysts (LPAs), Mariana Agban and Michael Cava conducted an unannounced complaint visit to investigate the above stated allegations. LPAs met with the Back up Administrator and explained the reason for the visit.

At 11:15 AM LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance withTitle 22 Regulations.LPAs During course of the investigation, interviews and record review were made. LPAs requested resident and staff roster. LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation.
Between 11:30 PM – 12:15 PM, LPAs conducted interviews with the Back up Administrator, two (2) staff
members out of four (4) and two (2) out of four (4) residents. (Continue on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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-20230919081545

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ZION ETERNITY RESIDENTIAL	FACILITY NUMBER: 197609688
	VISIT DATE: 09/29/2023

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
26
27
28
29
30
31
32

Allegation: Staff did not provide proper medication assistance to client in care
In regards to the allegation, it was reported that Resident 1 (R1) was refused their medication on or around 09/15/23. The medication that wasn't received was Trazodone. Interview with R1 revealed that R1 is taking the proper medication and confirms that they've been getting their medication as prescribed, therefore, denying this allegation. Review of R1's medication and Medication Administration Record (MAR) does not indicate any discrepancy. R1 is taking a total of four (4) medications, of which two (2) are PRN. MAR indicates that Trazodone is a PRN. Per review, it was provided only as needed, and documented when administered. Based on the information obtained, there was insufficient evidence to prove that staff did not provide R1 proper medication assistance. Therefore, the allegation is Unsubstantiated at this time.

Allegation: Staff did not treat client in care with dignity and respect.
It was alleged that 3 staff was treating R1 inappropriately. Interviews with 2 out 3 staff that were present during this investigation, including the back up administrator, denied the allegation. Interview with R2 also denied allegation. Resident 3 and Resident 4 are non verbal, therefore, these two residents couldn't be interviewed. Furthermore, there were no witnesses identified to the allegation that staff may have treated R1 inappropriately. Based on the information obtained, there wasn't enough evidence to prove that staff did not treat a client in care with dignity and respect. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of this report was signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2