<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530015
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:58:19 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
01/13/2025 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250113101825
FACILITY NAME:ZION ADULT RESIDENTIAL FACILITY 2FACILITY NUMBER:
365530015
ADMINISTRATOR:UNIQUE WATKINSFACILITY TYPE:
735
ADDRESS:12641 GARDEN WAYTELEPHONE:
(951) 305-5308
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 3DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Constance Odudu, LicenseeTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client's mattress is in disrepair
Staff did not maintain adequate foods at the facility for clients in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/152025 at 9:45 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to a staff. Staff informed Licensee Constance Odudu of the visit. Licensee met with LPA Serrano and LPA explained the purpose of the visit to licensee. The investigation consisted of file review, interviews with staffs and resident as well as observation.

The investigation was conducted by LPA Serrano. The allegations indicate:

#1 Client's mattress is in disrepair – Based on observation and staff interview, 2 out of 2 staff stated that the mattress is constantly being cleaned due to the clients having a behavior or medical issue that client soiled the bed frequently and the sofa in the living room. Based on observation the mattress is clean and in good repair.

*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 5
Control Number 56-AS-20250113101825
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 2
FACILITY NUMBER: 365530015
VISIT DATE: 01/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
#2 Staff did not maintain adequate foods at the facility for clients in care - Based on observation, resident and staff interview, 1 out of 1 resident and 2 out of 2 staff stated that the facility have adequate supply for 2 day perishable and 7 day non-perishable food. LPA observed good amount of food in the refrigerator and can goods in the food pantry.

During the investigation, LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to the licensee Constance Odudui.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/13/2025 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250113101825

FACILITY NAME:ZION ADULT RESIDENTIAL FACILITY 2FACILITY NUMBER:
365530015
ADMINISTRATOR:UNIQUE WATKINSFACILITY TYPE:
735
ADDRESS:12641 GARDEN WAYTELEPHONE:
(951) 305-5308
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 3DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Constance Odudu, LicenseeTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Bodies of water are accessible to clients in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 15, 2025 at 9:45 AM, Licensing Program Analyst (LPA) Eldin Serrano visited the facility to investigate the above mentioned allegation and deliver findings. LPA met with Licensee Constance Odudu to discuss the purpose of the visit.

The investigation consisted of observation and interviewing relevant parties. The allegation indicates that:

#1 Bodies of water are accessible to clients in care - Based on Interviews with 1 resident and 2 staff, they all stated that the facility has a jacuzzi that is always covered and it was used for clients scheduled activitity. LPA observed that the jacuzzi has a sturdy and heavy cover that has a latch to lock/open the cover but it does not have a locked mechanism that has a key to use the jacuzzi, which poses a potential health and safety issue of the clients in care. LPA will be issuing a citation.

*** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20250113101825
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 2
FACILITY NUMBER: 365530015
VISIT DATE: 01/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on LPA observations and interviews and record review conducted, the preponderance of evidence standard has been met, therefore, the allegation of Bodies of water are accessible to clients in care is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.

An exit interview was conducted where this report (LIC 9099), LIC9099D, and Appeal Rights were discussed and provided to Licensee Constance Odudu.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20250113101825
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 2
FACILITY NUMBER: 365530015
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
80087(e)(1)
1
2
3
4
5
6
7
80087 Buildings and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover...Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

1
2
3
4
5
6
7
Licensee will submit proof of the installed lock mechanism to the jacizzi by the plan of correction due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

Based on observation, records review, interviews with residents and staff; the licensee did not ensure that the bodies of water is locked and inaccessible by the clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5