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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003732
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:45:20 PM

Document Has Been Signed on 09/12/2022 03:45 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: 6DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosario Salaveria, administratorTIME COMPLETED:
04:00 PM
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On 09/12/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by Rosario Salaveria, Administrator and explained the purpose of the visit.
At approximately 2:50pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently six (6) clients in care, five (5) of which are back to attending their respective Day Programs regularly. Clients are observed relaxing in their respective bedrooms and appear clean and well taken care of. The six individual bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are kept in a locked drawer in the kitchen. Cleaning supplies are stored securely under lock in the attached garage where the laundry room is located. The centrally stored medication is located in a locked closet with a combination doorknob lock. LPA observed a sufficient supply of food and water present. Emergency supplies, water and rations are also stored in the attached garage. The facility has an ample supply of linen available for use by clients.

LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. Fire extinguishers present are charged and have up-to-date maintenance shown on the attached tags.

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded gazebo are present for the enjoyment of residents and visitors. The perimeter gates on both sides of the facility are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 I
FACILITY NUMBER: 306003732
VISIT DATE: 09/12/2022
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CONTINUED FROM FORM LIC809

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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