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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881103
Report Date: 04/14/2025
Date Signed: 04/14/2025 12:49:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Becky Mann
COMPLAINT CONTROL NUMBER: 56-AS-20250131142046
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: 4DATE:
04/14/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Melody Dagnino, Direct Support ProfessionalTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff leave resident in soiled bedding.
Staff do not provide proper incontinence care for resident.
Licensee does not ensure residents are provided with basic hygienic care items.
Staff does not seek medical care for resident(s)
Staff does not seek dental care for resident(s)
Licensee does not ensure resident is provided with proper clothing.
Licensee does not permit resident to go on outings.
Licensee does not provide adequate food service to residents.
Licensee does not ensure resident’s hearing device is in working condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Melody Dagnino, Direct Support Professional (DSP) and explained the purpose of the visit. The investigation consisted of LPA pertinent record reviews, observations and interviews with staff and residents.

The allegation that staff leave resident in soiled bedding. Six (6) staff interviewed denied leaving resident in soiled bedding. Two (2) residents interviewed stated that they were not left in soiled bedding.

The allegation that staff do not provide proper incontinence care for resident. Based on LPA observations, the facility does provide incontinence care for resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20250131142046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ZION ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361881103
VISIT DATE: 04/14/2025
NARRATIVE
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The allegation that licensee does not ensure residents are provided with basic hygienic care items. Six (6) staff interviewed stated that they do provide basic hygienic care items to residents. Two (2) residents interviewed stated that staff does provide basic hygienic care items.

The allegation that staff does not seek medical care for resident(s). Six (6) staff interviewed stated that they do seek medical care for residents. One (1) resident interviewed stated that not yet since they are new to the facility. Another resident stated that the doctor comes to the facility.

The allegation that staff does not seek dental care for resident(s). Six (6) staff interviewed stated that they do seek dental care for residents.

The allegation that licensee does not ensure resident is provided with proper clothing. Six (6) staff interviewed stated that the licensee does ensure resident is provided with proper clothing. One (1) resident interviewed stated that the licensee does provide proper clothing for resident.

The allegation that licensee does not permit resident to go on outings. Six (6) staff interviewed stated that licensee does permit resident to go on outings. Two (2) resident interviewed stated that licensee does permit resident to go on outings.

The allegation that licensee does not provide adequate food service to residents. Six (6) staff interviewed stated that licensee does provide adequate food service to residents. Two (2) resident interviewed stated that licensee does provide adequate food service to residents. Based on LPA observations, there is an adequate amount of food for residents in care.
The allegation that licensee does not ensure resident’s hearing device is in working condition. Six (6) staff interviewed stated that the licensee does ensure resident's hearing device is in working condition.

Based on evidence obtained during this investigation, the allegation above is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy of this report was provided to Melody Dagnino, DSP at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2