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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:03:01 PM

Document Has Been Signed on 09/20/2023 03:03 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 FACILITY 2FACILITY NUMBER:
365530015
ADMINISTRATOR:UNIQUE WATKINSFACILITY TYPE:
735
ADDRESS:12641 GARDEN WAYTELEPHONE:
(951) 305-5308
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 2DATE:
09/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Unique Watkins-AdministratorTIME COMPLETED:
03:05 PM
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
Licensing Program Analyst (LPA) Michelle Echeverrria conducted an unannounced case management visit to follow up on an incident report sent to licensing dated on 09/11/23. The incident involved staff 1 (S1) calling client 1 (C1) a profanity word. LPA was greeted and explained the reason for the visit to DSP, Taanalei Sofeni.

During today's visit, it was discovered that the facility placed (S1) on administrative leave after last shift worked on 09/08/23. LPA interviewed client and staff and found no issue.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to the Administrator, Unique Watkins who later arrived.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1