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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 07/06/2022
Date Signed: 07/06/2022 10:56:04 AM

Document Has Been Signed on 07/06/2022 10:56 AM - 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:
07/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Administrator Constance OduduTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. This is a second (2) pre-licensing inspection from 6/21/2022. This inspection is to confirm that all corrections have been made. At 9:30 LPA Allen was granted entry and LPA met with Administrator Constance Odudui LPA 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, All bedrooms are furnished with adequate furniture, bed, chair, closet, appropriate linens, adequate lighting .
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 109.1 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 with 5 days of perishables and 7 days of non-perishable food items. There was adequate seating for meals for all clients.
Continued ..........
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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: 07/06/2022
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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. LPA also observed additional hygiene supplies.

Yards/Outside:
LPA observed a shaded area with 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. Bedroom #3 carbon monoxide detector is attached to the ceiling and operating.

LPA observed the location where 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.

LPA observe activity supplies variety of reading materials such as magazines, newspapers.

An exit interview was conducted, and a copy of this report LIC 809 and LIC809-C was discussed and provided to the Administrator

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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