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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003732
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:16:41 PM

Document Has Been Signed on 11/07/2024 12:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MOUNT ZION HOMES IFACILITY NUMBER:
306003732
ADMINISTRATOR/
DIRECTOR:		SALAVERIA, ROSARIOFACILITY TYPE:
735
ADDRESS:26635 AVENIDA DESEOTELEPHONE:
(949) 916-3113
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Nicholas Novella, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Administrator Nicholas Novella was notified via telephone and arrived later to assist with the visit.

The facility is an Adult Residential Facility licensed for six clients, three of which can be non-ambulatory. There are currently six ambulatory clients in care. LPAs accompanied by caregiving staff conducted a tour of the physical plant. The facility is a one-story home with six private bedrooms for the clients and one staff bedroom. There are three bathrooms in the facility, two with walk-in showers and one with a bathtub, along with four half bathrooms located en-suite with some of the private bedrooms. Additional common areas include a dining room, living room, kitchen and laundry area situated in the attached garage.

The facility appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all six clients. Hot water measured at 110 degrees Fahrenheit in one bathroom and 114F on the other side of the house. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPAs observed hallways and walkways were free of obstruction.
LPAs observed both wall-mounted fire extinguishers on the premises are charged and have been maintained in 2024. Staff and LPAs tested smoke and carbon monoxide detectors which were found to be operational. Cleaning products and sharp instruments are stored in locked cabinets in the attached garage. Medication for each client is kept locked and secured in a locked closet. The backyard has one shaded seating area, and the exit gates on both sides of the house are unlocked and unobstructed. There are no bodies of water observed on the premises.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MOUNT ZION HOMES I
FACILITY NUMBER: 306003732
VISIT DATE: 11/07/2024
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CONTINUED FROM FORM LIC809
LPAs reviewed all six clients’ files and medications as well as Personal and Incidental funds records which were verified to correspond to the amount noted on the ledger. Receipts are present and ledgers are signed by the clients. LPAs reviewed four staff files. All files of staff and clients contained all required documentation. All current staff members are cleared and associated with health screenings and current first aid training on file.

Two staff interviews were conducted during the visit. One client was present at the start of the visit but quickly left as her transportation to day program was observed to arrive. All clients were either at their respective day programs or away on outings during the visit. No client interviews conducted.

The administrator certificate for administrator Rosario Salavera is current and valid until June 2026. The renewal for Mr. Novella is confirmed to have been submitted to the Administrator Certification Bureau. The Emergency and Disaster Plan was reviewed, fire and emergency drills are conducted and documented as required.



No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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