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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881103
Report Date: 05/24/2023
Date Signed: 05/24/2023 01:47:01 PM

Document Has Been Signed on 05/24/2023 01:47 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: 3DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Constance Adudu-LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On 05/24/23 at 08:54 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Caregiver, Eileen Mendoza and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there is currently 2 residents in the facility and 1 in day program. LPA began the tour of the facility with Caregiver Mendoza.

The facility has 4 bedrooms, 4 bathrooms, a kitchen, dining area, living room, loft, office, laundry room, garage and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 70 degrees Fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the upstairs hallway cabinets. LPA inspected residents bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 112.5 degrees Fahrenheit. The facility is equipped with operating (2) fire extinguishers, smoke alarms and carbon monoxide alarms. Last fire drill was conducted on 04/29/23 at 09:30 AM. LPA observed that the facility has been conducting a drill quarterly during the same shift. Deficiency issued. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. LPA observed that the Emergency Disaster plan has not been reviewed since 01/01/21. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for residents/staff files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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Document Has Been Signed on 05/24/2023 01:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/24/2023 at 11:40 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: ZION ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361881103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in conducting a drill at least quarterly for each shift for 3 out of 3 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee will conduct a meeting with all staff in reviewing regulation 1565(c) and submit proof of attendance by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


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: 05/24/2023
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Yards/Outside:
One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food, water, and emergency disaster kits were observed inside the facility.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched to MARS.

Deficiency and technical violation was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102, and appeal rights were discussed and copies were provided to Licensee, Constance Odudu.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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