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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:42:38 PM

Document Has Been Signed on 06/21/2022 12:42 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ZION ADULT RESIDENTIAL FACILITY 2FACILITY NUMBER:
365530015
ADMINISTRATOR:ODUDU, CONSTANCEFACILITY TYPE:
735
ADDRESS:12641 GARDEN WAYTELEPHONE:
(909) 749-0974
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
06/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Administrator Constance OduduTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. I met with Administrator Constance Odudui. An initial application to operate an Adult Residential Care facility (ARF) was submitted to the Central Applications Bureau (CAB) on 4/1/2022 for a total capacity of four (4)) ambulatory clients . The fire clearance was granted on 4/27/2022.
At 9:23 LPA Allen was granted entry and observed the following:
Structure:
Facility was a single house with four(4) resident bedrooms, two(2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway.
Bedrooms:
Resident bedroom #1, #2, #3 and # 4 will accommodate ambulatory residents, The master bedroom is furnished with bed, chair, closet, appropriate linens, adequate lighting with smoke detector
Bedrooms 2,3 & 4 need chairs which have been ordered with delivery date of July 1, 2022.
Bathrooms:
The bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. LPA tested the water temperatures in the Master bathroom that measured at 108.1 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked hallway closet located near the kitchen. There was adequate room for food and storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition but there was not enough perishables and non-perishable food items at the time of LPA visit. There was adequate seating for meals for all clients.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ZION ADULT RESIDENTIAL FACILITY 2
FACILITY NUMBER: 365530015
VISIT DATE: 06/21/2022
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LPA observed.laundry room with washer and dryer located near the kitchen. All cleaning supplies and laundry detergents were observed in garage secured in a locked cabinet..
Living/Family room:
LPA observed the living/family room with adequate seating for all clients to watch TV. LPA also observed that there was a working telephone line
Linens and Hygiene Supplies:
LPA observed an adequate supply of linens was stored in a cabinet in the main hallway.
Yards/Outside:
LPA observed a shaded area without adequate seating for clients, staff or visitors. There was no body of water observed during the visit.
Emergency Phone Numbers, and Exit Plan:
LPA observed facility sketch and Let-Us-No poster in the main entrance of the house.
General items:
LPA observed two (2) fire extinguishers were charged. and seven (7) carbon monoxide detectors with one(1) in bedroom #3 not connected/attached to the ceiling.
The First Aid kit with required components, medications, P&I will be locked in closet near the kitchen area.
The staff and residents files will be locked and stored in office and the entryway of the home.

Pre-Licensing is incomplete and the following corrections to be resolved.
  • Obtain a separate 72-hour emergency food supply
  • Obtain separate emergency water
  • Obtain 30-Days of PPE supplies
  • Fix or remove light fixture in the backyard
  • Fix or replace Carbon Monoxide detector in bedroom #3
  • Obtain a 5 day supply of perishable food and a 7 day supply of non-perishable food items.
  • Obtain adequate seating for bedrooms 2,3 & 4
  • Obtain adequate seating for shaded outside area.


An exit interview was conducted and discussed, and a copy of this report was given to Administrator Constance Odudu.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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