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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:30:11 PM

Document Has Been Signed on 09/28/2023 12:30 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:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Sam Adubi-DSPTIME COMPLETED:
12:35 PM
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On 09/28/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Sam Adubi, introduced self and stated purpose of the visit.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining, living room, family room, laundry room, office attached garage, and backyard with shed. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112.7 degrees fahrenheit. The facility is equipped with operational smoke detectors, charged fire extinguisher, and first aid kit. LPA observed that the facility does not have any carbon monoxide alarms. Deficiency issued. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. LPA observed that the Emergency Disaster Plan does not have a signature and date. Deficiency issued. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in a locked closet inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits and emergency water. There are no firearms, ammunition or bodies of water. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard and 1 shed. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 365530015
VISIT DATE: 09/28/2023
NARRATIVE
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed clients file for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that staff's orientation training was missing administrator's/trainer's signature. Deficiency issued. Medication and P& I was audited and matched with record.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to DSP, Sam Adubi.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/28/2023 12:30 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/28/2023 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in having one or more carbon monoxide alarm in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator stated that she will purchase a carbon monoxide alarm and install it in the facility. Administrator will provide LPA with picture of receipt and installation via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/28/2023 12:30 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/28/2023 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in signing staff's orientation training record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator stated that she will sign the orientation training record for staff and submit proof via email by POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in reviewing and signing the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator stated that she will review/updata the emergency disaster plan annually and submit proof of signature to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
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