197609688-12-13-2023-31-AS-NGID-CZRVYL-20240123155114

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609688
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:47:13 PM

Unsubstantiated

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 RESIDENTIAL		FACILITY NUMBER:	197609688
ADMINISTRATOR:	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:	12/13/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jhomer Yuson		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not properly storing resident's medication

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

Unsubstantiated

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)

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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 not properly storing resident's medication

In regards to the allegation above, it was reported that Resident #1 (R1) had access to her medication and that it was stored in her personal drawer. Interview with R2 revealed that clients are not allowed near the medication when it is being dispensed nor are they allowed access to the medication therefore, denying this allegation. Resident #3 (R3) and Resident #4 (R4) are non verbal, therefore, these two residents couldn't be interviewed. Review of R1's medication and Medication Administration Record (MAR) does not indicate any discrepancy, however it did reflect that on 11/23/23 R1 was not in the home for the PM doses. R1 is taking a total of four (4) medications, of which two (2) are PRN. Per a phone interview with Administrator Anderson and Conservator it was revealed that Conservator failed to inform facility that R1 had obtained medication other than what is normally prescribed. Conservator revealed that medication that was in possession of R1 was obtained by R1 on R1’s own. Furthermore, Conservator admitted neglecting to inform the facility that R1 had been treated at the hospital on 11/23/23 and that the prescription was obtained by R1. Based on the information obtained, there was insufficient evidence to prove that Staff are not properly storing resident's medication. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of this report was signed and delivered.

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)

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