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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 10/05/2023
Date Signed: 10/05/2023 05:08:34 PM

Document Has Been Signed on 10/05/2023 05:08 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charles ChantawansriTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Melissa Spaeth and Lorena Casillas conducted an unannounced annual visit on 10/05/2023. LPAs were greeted by the House Manager and stated the purpose of the visit. The caregiver confirmed there are four clients living at the facility.

LPA and house managerr began the tour at 9:54 am until 10:35 am. LPA observed the following:

Locked Closets –Upon entering the facility, LPAs observed cleaning solutions were locked in the closet. A second hallway closet was locked and contained personal hygiene items.

Kitchen – LPA observed the kitchen area was neat and clean. LPAa observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. The clients' medications and first aid kit were locked in a kitchen cabinet. The fire extinguisher was located near the kitchen.



Common areas – LPA observed the living room/dining room contained comfortable seating and the dining room area contained a table with bench seats.

Laundry Area - The laundry room contained the washer and dryer.

Garage – The garage was locked and is the facility office which contained the emergency food, an additional refrigerator stocked with food, locked knives, and resident/staff files
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ZION ETERNITY RESIDENTIAL
FACILITY NUMBER: 197609688
VISIT DATE: 10/05/2023
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Bathrooms – LPA observed the two bathrooms. Both bathrooms contained hand soap, paper towels, slip resistant mats and covered trash cans. The water temperature was tested in Bathroom 1 at 10:20 am and was 115.5F. LPAs observed the toilet tank top was missing in Bathroom 1 and a piece of plastic was wrapped around the top. The house manager stated the toilet tank top was broken by a resident but could not remember the date this occurred. The house manager stated a new tank will be installed on Saturday.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:10 am and were operable.

Backyard - LPA observed the backyard which has a shaded area. LPA observed a locked storage building which contained additional furniture. The gate leading from the backyard to the front yard was not locked.

LPA reviewed client records at 10:45 am until 11:05 am. LPAs observed a client's records (C1) were missing. House Manager stated since C1 is a new resident, staff are still gathering the documentation.

LPAs reviewed staff records at 11:10 am until 11:25 am. LPA viewed resident's medications at 11:30 am until 11:45 am. LPA reviewed P&I records at 11:49 until 12:10 pm.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, a copy of the appeal rights were given to the house manager. A copy of the signed report was also given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 05:08 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/05/2023 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ZION ETERNITY RESIDENTIAL
FACILITY NUMBER: 197609688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations,, the licensee did not comply with the section cited above in one of the two bathrooms. The toilet tank top was missing in Bathroom 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Administrator will send a snapshot via email to LPA Spaeth of the repaired toilet in Bathroom 1
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above in one of four clients' records. Client C1's file did not contain the required documenation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator will send a copy of Client 4's records to LPA Spaeth via email which includes Admissions Agreement, Medical Assessment, consent forms, and Personal Rights documentation.
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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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