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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609688
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:36:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/07/2023 and conducted by Evaluator Lorena Casillas
COMPLAINT CONTROL NUMBER: 31-AS-20231207114655
FACILITY NAME:ZION ETERNITY RESIDENTIALFACILITY NUMBER:
197609688
ADMINISTRATOR:ANDERSON MUNOZFACILITY TYPE:
735
ADDRESS:43642 DANA DRTELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jhomer YusonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are locking the fridge
INVESTIGATION FINDINGS:
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On 12/13/23 Licensing Program Analysts (LPAs), Lorena Casillas and Leslie Ngo-Castaneda conducted an unannounced complaint visit to investigate the above stated allegations. LPAs met with the Back Up Administrator Jhomer Yuson and explained the reason for the visit. LPAs were joined by North Los Angeles Regional Center staff Aiyana Brackin and Supervisor Fernanda Zavalza.

At 10:20 AM LPA Ngo-Castaneda conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. During course of the investigation, interviews and record review were made. LPAs requested resident and staff roster. LPAs requested copies of pertinent information which include, but are not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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 3
Control Number 31-AS-20231207114655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/13/2023
NARRATIVE
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Between 11:00 AM – 12:00 PM, LPAs conducted interviews with the back up Administrator, two (2) staff members out of two (2) and one (1) out of four (4) residents.

Allegation#1: Staff are locking the fridge



It was alleged that Staff are locking the fridge. During LPA’s visit the fridge was not locked or chained. Interviews with two (2) of the three (3) staff that were present during this investigation, denied the allegation. Interview with the back up administrator, admitted to the allegation, however this action was taken temporarily due to Resident #4 (R4) harming herself and destroying food. Interview with R2 also confirmed that R4 will hurt herself and destroy food if given access to the fridge. R2 states that food is never denied when requested to any of the clients in care. Resident #3 (R3) and Resident # 4 (R4)are non verbal, therefore, these two residents couldn't be interviewed. Based on the information obtained, staff admitted to locking the fridge as a temporary deterrent for R4, however food is not denied, and clients have access to food when requested. In order to deter R4’s behavior and self harm, the majority of the food is stored in the fridge located in the locked garage and redirection is provided to clients. Therefore, based on information obtained the allegation is Substantiated at this time.


Citation Issued. Appeal rights discussed and provided. Exit Interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20231207114655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2023
Section Cited
CCR
82072(a)(3)
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82072(a)(3)Personal Rights (a) Except for ..., each client shall have personal rights which include, but are not limited to... : (3) To be free from corporal or unusual punishment, ...withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
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Administrator provided proof of inservice training. Administrator will no longer lock fridge.
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Based on observation, interview, and record
review, licensee locked fridge denying access to clients, this poses a Health, Safety, and Personal risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3