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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 06/01/2026
Date Signed: 06/01/2026 02:24:33 PM

Document Has Been Signed on 06/01/2026 02:24 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:		CHARLES CHANTAWANSRIFACILITY TYPE:
735
ADDRESS:43642 DANA DRTELEPHONE:
(661) 494-8739
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
06/01/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:CHARLES CHANTAWANSRITIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 06/01/2026 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. On April 30, 2026, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office. As a result of that NCC, the facility was placed on a one-year compliance plan. LPA arrived at 09:50 am and was greeted by the Administrator, Charles Chantanwansri, LPA explained the purpose of the visit.

Administrator informed LPA that one (1) client was attending their day programs. LPA observed one (1) client was currently sleeping. One (1) client was awake and lounging in the living room and One (1) client is currently hospitalized. At approximately 10:45 a.m., LPA and Administrator took a tour of the physical plant. LPA conducted a physical plant tour and observed the facility maintaining a comfortable temperature of 72°F. 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.

Today’s focus was Personal Rights, Care and Supervision and Emergency Intervention Prohibitions. LPA also addressed information reported that staff have allegedly pushed a client in care. Per the NCC, the Licensee will hire a consultant to provide training on Title 22 regulations for the facility administrator and staff with a minimum of four hours per month for the first three months and for one hour per month for the remaining year.


Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2026
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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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: 06/01/2026
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LPA reviewed the staff training files. Personal Rights and Care and Supervision training was held on 05/11/26 for 1.5 hours. LPA reviewed the staff training files for Emergency Intervention Prohibitions held 5/20/26 for 2.5 hours. LPA verified that all staff have completed the required training. LPA also verified that the material covered was provided by a consultant.

LPA interviewed the Administrator regarding the information received pertaining to staff #1 (S1) that was observed pushing a client by staff #2 (S2). Administrator stated that an internal investigation was conducted and that S1 denied pushing any client. Administrator added that S2 reported this incident to them, however when Administrator interviewed client #1 (C1), C1 denied being pushed by S1. Subsequently S2 resigned and refused to answer any further questions. LPA attempted to interview S2 over the phone, however S2 stated that they did not want to answer any questions. Additionally, S2 stated that they do not speak clear English, LPA offered to speak to S2 in Spanish as S2 stated that this was their primary language, but S2 refused and terminated the phone call. LPA interviewed S1 over the phone and S1 denied the allegation stating that at no point have they pushed any clients. LPA interviewed C1 who also denied the incident. Since S1 and C1 denied the incident happening and since the Administrator has taken the appropriate actions to ensure that the incident was investigated, there are no deficiencies cited at this time.

No citations issued. Exit interview conducted and a Copy of this report provided to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026
LIC809 (FAS) - (06/04)
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