<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:14:50 PM

Document Has Been Signed on 06/14/2022 01:14 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ZION ETERNITY RESIDENTIALFACILITY NUMBER:
197609688
ADMINISTRATOR:KING, MARLONFACILITY TYPE:
735
ADDRESS:43642 DANA DRTELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Anderson Munoz, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 9:55 am and was greeted by caregiver Eddie Hernandez. Two (2) clients were observed in the living room relaxing. The Administrator arrived at 10:44 am. LPA informed the Administrator 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. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize hands.

A tour of the physical plant was conducted with Administrator at 10:46 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) clients. The facility is Fire Cleared for four (4) ambulatory.

Food Inspection
LPA conducted a tour of the kitchen around 10:50 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to clients in care. The medication cabinet and first aid kit was observed to be locked.

Laundry
At 10:54 am, LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ZION ETERNITY RESIDENTIAL
FACILITY NUMBER: 197609688
VISIT DATE: 06/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 69°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:15 am. There one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full. The Administrator will provide a receipt of last service date.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. Bedroom #3 is now empty due to an incident that occurred 6/07/22. The bedroom is blocked off and inaccessible to client’s in care. LPA observed a broken window and broken blinds. The Administrator stated the window repair is scheduled for Friday 6/17/22 and will provide verification of the scheduled repair.

Bathrooms
At 11:00 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 11:03 am and measured within regulation at 102.9 degrees F.

Physical environment
LPA toured the outside area of the facility at 11:04 am. LPA observed a covered shaded area for clients. No bodies of water on the premises. LPA observed two locked sheds. LPA observed various items (broken furniture, and glass from a recent incident) that needed to be removed or stored in a locked shed away from clients in care. The Administrator immediately removed and locked away all items.

Garage
At 10:55am, LPA observed the garage to be attached to the facility and currently being used for emergency food storage, 90-day PPE supply, and repairable furniture.

Administrative: Annual fee is current.


An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2