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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003732
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:42:09 PM

Document Has Been Signed on 11/08/2021 01:42 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MOUNT ZION HOMES IFACILITY NUMBER:
306003732
ADMINISTRATOR:SALAVERIA, ROSARIOFACILITY TYPE:
735
ADDRESS:26635 AVENIDA DESEOTELEPHONE:
(949) 916-3113
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosario SalaveriaTIME COMPLETED:
01:50 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry by staff. LPAs observed all staff were wearing masks. LPAs met with Administrator Rosario Salaveria, her Administrator's certificate expires on 6/22/2022. Facility is a single story house with 7 bedrooms and 8 bathrooms and a 2 car attached garage. LPAs and Administrator toured the facility. LPAs observed the kitchen is clean and has a 2 day perishable and 7 day non-perishable food supply on hand. LPAs observed all fire extinguishers are fully charged. LPAs observed all medication is kept locked in a closet. LPA inspected the first aid kit. First Aid kit had all the required elements. The smoke detectors/carbon monoxide detectors tested operational. LPAs observed all the bedrooms had the required furnishings. Hot water measured 111.5 degrees Fahrenheit to 120.7 degrees Fahrenheit. LPAs observed that 2 out of the 8 bathroom exhaust fans were inoperable. LPAs observed 2 out 8 bathroom lights were inoperable. All bathrooms had 2 lighting fixtures. The garage is used for storage and inaccessible to clients. LPAs observed extra supplies stored in the garage. LPAs toured the backyard. LPAs observed flooring tiles stacked next to the exit pathway. Both exit gates are operational. The covered patio has chairs for the residents to sit. No bodies of water observed. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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