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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881103
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:48:09 AM

Document Has Been Signed on 11/04/2022 09:48 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ZION ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
361881103
ADMINISTRATOR:WATKINS, UNIQUEFACILITY TYPE:
735
ADDRESS:11025 MESA LINDA ST.TELEPHONE:
(909) 749-0974
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Unique Watkins Administrator TIME COMPLETED:
09:55 AM
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Licensing Program Analysts (LPA) Bernadette Allen conducted an unannounced visit to the facility to investigate complaint control number: 56-AS-20221028111812. Upon arrival LPA Allen was informed that (LPA's) Anna Bueno and Amber Coleman had conducted the investigation on 11/3/2022.

An exit interview was conducted where this report was discussed with administrator Unique at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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