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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881103
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:25:31 PM

Document Has Been Signed on 03/20/2024 03:25 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: 2DATE:
03/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Unique Watkins-AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to follow up on an incident report sent to licensing on 2/26/24. LPA introduced self and stated the purpose of the visit to Administrator, Unique Watkins.

During today's visit, LPA performed a health and safety check, reviewed records and interviewed staff. Interview and record review revealed that staffing was not maintained as specified by the Regional Center making the day shift short staffed during the occurrence of the incident.

One deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were discussed and provided to Unique Watkins.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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Document Has Been Signed on 03/20/2024 03:25 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/20/2024 at 03:01 PM
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: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2024
Section Cited
CCR
85065.5(a)(1)

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85065.5 Day Staff-Client Ratio
(a) Whenever a client who relies upon others to perform all activities of daily living is....requirements shall be met:
(1) For Regional Center clients, staffing shall be..to three such clients. This requirement was not met as evidenced by:
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Administrator stated that the facility recently hired and scheduled 4 new staff. LPA verified Guardian. POC is cleared.
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Based on observation and record review, the administrator did not comply with the section cited above in scheduling sufficient staff during the day which poses a potential health, safety or personal rights risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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