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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:44:29 PM

Document Has Been Signed on 06/19/2024 03:44 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 ETERNITY RESIDENTIALFACILITY NUMBER:
197609688
ADMINISTRATOR/
DIRECTOR:		ANDERSON MUNOZFACILITY TYPE:
735
ADDRESS:43642 DANA DRTELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Charles ChantanwansriTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 01:00 pm and was greeted by a staff member. LPA contacted the Administrator and was informed that they were not available and assigned House Manager Charles Chantanwansri to sign the report. LPA informed the House Manager (HM) of the purpose of the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 04/23/21) to make sure licensee was following current infection control recommendations.

A tour of the physical plant was conducted with HM at 01:30 pm. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory clients.

Kitchen: LPA conducted a tour of the kitchen at 01:35 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects to be locked and inaccessible to clients in care. The medication cabinet and first aid kit were observed to be locked.

Laundry: At 01:40 am, LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.

Common areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 01:45 pm. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 11/03/2023.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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 ETERNITY RESIDENTIAL
FACILITY NUMBER: 197609688
VISIT DATE: 06/19/2024
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms: At 01:50 pm LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 1:52 pm and measured within regulation at 105 degrees F.

Physical environment: LPA toured the outside area of the facility at 01:55 pm. LPA observed a covered shaded area for clients. No bodies of water on the premises.

Garage: At 02:00 pm, LPA observed the garage to be attached to the facility and currently being used for emergency food storage, 90-day PPE supply and additional storage.

Administrative: Annual fee is current. LPA collected LIC500, Surety Bond, Administrator Certificate and Client roster.

Staff and Client Interviews: At 02:15 pm LPA conducted interviews.

Staff Records: At 02:40 pm LPA conducted staff file reviews.

Client Records: At 03:00 pm LPA conducted client file reviews.

Medication: At 03:30 pm LPA and HM conducted medication and medication log reviews.

No citations issued. An exit interview was conducted, and a copy of this report was given to HM.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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