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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609688
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:59:06 PM

Document Has Been Signed on 09/29/2023 01:59 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: 4DATE:
09/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jhomer YusonTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a Case Management (CM) visit to the facility to follow up on an Incident Report (IR), that was received on 09/27/23. It was reported that on or around 09/23/23, Resident 1 (R1) was handled inappropriately by Staff 1 (S1). Internal investigations was made by facility administrator, Anderson Munoz, and based on the information the administrator has obtained, there wasn't enough information to corroborate S1 handling R1 inappropriately. Today's investigation consisted of interviews with two (2) out of two staff, and back up administrator, Jhomer Yuson. Interviews were also made with two (2) out of four (4) residents. Reason being is because Resident 3 (R3) and Resident 4 (R4) were non-verbal. Based on interviews obtained, there was insufficient evidence to corroborate that S1 handled R1 inappropriately. Furthermore, there were no witnesses identified to the incident. Therefore, no citations issued will be issued at this time. Back up administrator was advised and a copy of this report given.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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