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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881103
Report Date: 03/19/2026
Date Signed: 03/19/2026 02:50:30 PM

Document Has Been Signed on 03/19/2026 02:50 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/
DIRECTOR:		WATKINS, UNIQUEFACILITY TYPE:
735
ADDRESS:11025 MESA LINDA ST.TELEPHONE:
(760) 244-0948
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 4DATE:
03/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:David Adubi- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Staff, Booker Fowler and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 3 clients in the facility and 1 in program. Administrator, David Adubi shortly arrived to assist with the inspection.

The facility has 4 bedrooms, 4 bathrooms, a kitchen, dining area, living room, loft, office, laundry room, garage and backyard. LPA completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 78 degrees Fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the upstairs hallway cabinets. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature which tested at 109 degrees Fahrenheit. The facility is equipped with operating fire extinguishers, smoke alarms and carbon monoxide alarm. LPA observed that the facility did not have a carbon monoxide for the second floor. Deficiency issued. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for clients/staff files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition. LPA observed the entrance window blinds were broken, laminate floor in the family room uneven and broken on different connecting areas, a client's bedroom door with a fist size hole, another client's window blinds broken along with their closet door off the sliding rail. Deficiency issued.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/19/2026
NARRATIVE
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Food Service: Non-perishable and perishable food supply does not meet the required amount. Deficiency issued. Dishes, cups, and utensils were also stored properly. Emergency disaster kits were observed inside the facility.

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.

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 client 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. LPA observed that one client had four expired PRN medications and no new orders received. Deficiency issued. P&I was audited and matched with the ledger. LPA reviewed the facility's infection control plan, emergency disaster plan, emergency drills, liability insurance and surety bond. LPA observed that the surety bond had a different facility address. Technical violation issued. LPA observed that the Infection Control Plan was not reviewed/updated annually. Deficiency issued. LPA observed that the emergency drills were only conducted during one shift for a year. Deficiency issued. LPA observed the Emergency Disaster Plan was not reviewed/updated annually. Deficiency issued.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Administrator, David Adubi.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/19/2026 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/19/2026 at 02:03 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: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not reviewing/updating the infection control plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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Administrator stated that he will review/update the infection control plan and proof to LPA via email by POC due date.
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above by not having a carbon monoxide alarm on the second floor which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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Administrator stated that he will purchase a carbon monoxide alarm for the second floor and will send proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/19/2026 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/19/2026 at 02:03 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: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by not repairing the broken entrance window blinds, uneven and broken laminate floor in the family room on different connecting areas, a client's bedroom door with a fist size hole, another client's broken window blinds along with their closet door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Administrator stated that he will fix all the addressed issues and will send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by not having 7 days of nonperishables and 2 days of perishables for the all of the clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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Administrator stated that he will purchase the required amount of groceries and submit proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/19/2026 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/19/2026 at 02:03 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: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not discarding and replacing the four expired PRN medications for one client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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Administrator stated that monthly medication audits will be conducted and a statement of understanding on the regulation cited will be sent to LPA via email by POC due date.
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, interview and record review, the administrator not comply with the section cited above by not conducting emergency drills for each shift quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2026
Plan of Correction
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Administrator stated that the next emergency drill will be conducted on a different shift from the last drill and will send proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/19/2026 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/19/2026 at 02:03 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: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the administrator did not comply with the section cited above by not reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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3
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Administrator stated that he will review/update the Emergency Disaster Plan and send proof to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
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