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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881103
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:17:40 PM

Document Has Been Signed on 12/20/2022 03:17 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ZION ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
361881103
ADMINISTRATOR:WATKINS, UNIQUEFACILITY TYPE:
735
ADDRESS:11025 MESA LINDA ST.TELEPHONE:
(760) 244-0948
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Unique Watkins, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Zion Adult Residential Facility to make an unannounced case management visit due to a recent death of a resident while in care of the facility. LPA introduced self and stated the purpose of the visit. LPA was greeted by Unique Watkins, Administrator and invited inside of the facility. LPA was asked to sign in and have temperature taken. Administrator contacted the Licensee to notify her of LPA's visit. Licensee arrived later during LPA's visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Resident #1 (R1).

LPA and Administrator took a seat in the living room to conduct an interview. LPA asked Administrator to explain the incident and how it happened. Administrator reported that she was not on shift the evening of 12/17/22 but reported to work on 12/18/22 at 8:00am for her shift. Administrator relieved the Licensee of her duties. Administrator was only staff on duty for the day. Licensee gave report to Administrator, which did not specify anything unusual. The evening prior (12/17/22) the resident returned from day program, had a snack, went outside with another resident to smoke. When she returned back inside she played dominoes, ate dinner, assisted another resident with making their bed, took medications and went to bed herself. The next morning, Licensee informed Administrator that she did not get a chance to assist the residents with

***Continued on LIC809-C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ZION ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361881103
VISIT DATE: 12/20/2022
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medication; which meant the Administrator would need to assist with medications. Administrator stated that the resident routinely has a hard time waking up in the mornings; which causes staff to knock on her door, call her name to wake her up. On some occasions the resident will get up while staff is present and go back to bed when staff leaves the room. The day of 12/18/22. Administrator reported that she called resident 2/3 times, no answer. She then went upstairs to the resident's room knocked on the door and called the resident's name. There was no response. Administrator then nudged the resident's mattress, no success. Administrator noticed the resident's arm was protruding off of the mattress, so she felt for a pulse - no success. Administrator called 911 who instructed her to get the resident off the bed. The resident's weight is approx. 400lbs. so the resident's were directed to help get the resident off the bed. Once on the floor, CPR was performed for approx. 5 minutes before EMT's arrived and took over. EMT's performed CPR and utilized an AED in efforts to save the resident's life. EMT's pronounced resident's death at 9:52am on 12/18/22. Administrator provided EMT's the resident's medical information. The San Bernardino Sheriff Dept. made a visit and interviewed Administrator. As well as the county Coroner. The resident's mother was notified and arrived on seen. The Coroner's permitted the resident's Mother to view the resident before leaving the facility.

Administrator provided LPA with the resident's D/C paperwork from previous hospital visits, a letter certifying the resident's death and the Police Report Number. No death certificate has be provided to the facility, Administrator agreed to contact the coroner to request it.

LPA walked through the facility, observed no deficiencies. An exit interview was conducted where this report was discussed and provided to the Administrator and Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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