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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881699
Report Date: 01/28/2025
Date Signed: 01/28/2025 12:41:09 PM

Document Has Been Signed on 01/28/2025 12:41 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ZECHARIAH HOMEFACILITY NUMBER:
331881699
ADMINISTRATOR/
DIRECTOR:		MADERA, LARISAFACILITY TYPE:
737
ADDRESS:29220 VIA LAS PALMASTELEPHONE:
(760) 600-7578
CITY:THOUSAND PALMSSTATE: CAZIP CODE:
92276
CAPACITY: 4CENSUS: 3DATE:
01/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Larisa MaderaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an unannounced visit to the facility for a health an safety check. The LPA met with Administrator Larisa Madera, and informed her of the purpose for the visit and was granted access.

The facility is a single story building and consists four(4) resident bedrooms, three (3) bathrooms, a gated pool meeting the department's requirement. There are currently three (3) residents in care. LPA toured the facility for the purpose of a health and safety check. LPA observed sufficient staff supervising resident in care during today's visit. LPA did not observe the required two days of perishable food at the facility. A citation will be issued.
An exit interview was conducted, and a copy of this report was provided to Administrator Larisa Madera
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/28/2025 12:41 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 01/28/2025 at 10:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ZECHARIAH HOME
FACILITY NUMBER: 331881699

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
87555(b)(26)

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General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement was not met at evidenced by:
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Licensee will ensure to buy enough perishable food supplies meeting the requirements and sent receipt and picture of the supplies to LPA by POC
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Based on LPA’s observation and interviews, Licensee did not comply with the section cited not having enough two days supplies of perishable food for the three (3) residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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