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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881699
Report Date: 12/26/2024
Date Signed: 12/26/2024 11:07:31 AM

Document Has Been Signed on 12/26/2024 11:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ZECHARIAH HOMEFACILITY NUMBER:
331881699
ADMINISTRATOR/
DIRECTOR:		KRAVTSOVA, TAMARAFACILITY TYPE:
737
ADDRESS:29220 VIA LAS PALMASTELEPHONE:
(760) 600-7578
CITY:THOUSAND PALMSSTATE: CAZIP CODE:
92276
CAPACITY: 4CENSUS: 0DATE:
12/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ericka MunozTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an announced pre-licensing inspection at the facility and met with Administrator Ericka Munoz

Application: The inspection is for a Change of Ownership for an Adult Residential Facility (ARF) application. The Riverside County Fire Department approved a fire clearance on 12-20-2024 for four (4) non-ambulatory clients.

Buildings and Grounds: The facility is composed of four (4) bedrooms, two (2) bathrooms and a kitchen area. Water temperature was measured at 107 F. The interior and exterior walkways of the facility were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are hard wired in working order. There is a pool with a locked gate meeting the department’s requirement and there are no weapons stored in the facility. Client bedrooms are fully furnished, and privacy is available. Outdoor areas have sufficient room for activities and leisure. A washing machine and dryer were available and in working order. The facility has a working phone witnessed by calling the phone number.

Storage and Supplies: Medications and residents files will be stored in the medication room, inaccessible to any unauthorized individuals. Secured locked medication room is available for staff files. A complete first aid kit was observed to be available. Cleaning supplies will be stored in a in the medication room . Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of August 26th, 2025.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ZECHARIAH HOME
FACILITY NUMBER: 331881699
VISIT DATE: 12/26/2024
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and freezer are in working order. Sharps knives will be stored in a locked medication room, available only to authorized individuals.

Forms: The following signs were observed to be posted at the facility: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch, ombudsman poster. LPA verified the Administrator's Certification, with an expiration date of 12-23-26, and CPR certification with the expiration date of 10-4-26

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicant is scheduled to complete Comp III on 12-26-24. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Erika Munoz.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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