197609688-4-29-2025-31-AS-LCAS-DG7U6S-20250429151849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:18:57 PM

Document Has Been Signed on 04/29/2025 03:18 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 RESIDENTIAL		FACILITY NUMBER:	197609688
ADMINISTRATOR/ DIRECTOR:	ANDERSON MUNOZ		FACILITY TYPE:	735
ADDRESS:	43642 DANA DR		TELEPHONE:	(818) 687-3830
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 4	DATE:	04/29/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Jessica Cruz		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced case management visit. LPA met with House Manager (HM) Jessica Cruz and disclosed the reason for the visit. Today’s case management visit is to follow up on a series of special incident reports (SIR) previously reported between February 2025 to April 2025 by the facility in which Client #1 (C1) is continuously attacking staff as well as eloping. The purpose of the visit is to obtain additional information regarding these incidents.

On 02/03/25 C1 was taken to the emergency room where C1 refused to be seen and walked out. C1 and staff returned to the facility where the behavior escalated to physical aggression where C1 caused property damage. C1 was taken back to the hospital and was placed on psychiatric hold for three (3) days before being released back to the facility. Subsequently C1 has had numerous episodes of eloping and aggressive behavior towards other clients and staff. LPA interviewed HM who stated that C1 visited the urgent care on 4/13/25 and medication was adjusted. Since the adjustment the episodes have subsided significantly, to the point where only one (1) episode of a behavior has happened, however that episode only involved C1 calling 911 due to attention seeking. Facility is working with behavioral staff, NLARC and 1:1 staff to try to manage C1’s behavior. Facility has sent appropriate special incident reports to Community Care Licensing and NLARC. Currently C1 has maintained good behavior and has shown improvement in demeanor. LPA observed C1 interacting with HM in a positive manner while trying to resolve a mistake that C1 made with the laundry. LPA observed that a behavior was not triggered by a difficult situation that C1 was going through, it was observed that C1 successfully managed to resolve the issue with HM’s help. Since the facility has taken the appropriate actions to ensure staff are appropriately caring for C1 and that protocols are being followed for C1’s behaviors, there are no deficiencies cited at this time.

Exit interview conducted. Copy of report provided to HM.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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