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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:52:26 AM

Document Has Been Signed on 07/12/2024 11:52 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ZION ADULT RESIDENTIAL FACILITY 2FACILITY NUMBER:
365530015
ADMINISTRATOR/
DIRECTOR:		UNIQUE WATKINSFACILITY TYPE:
735
ADDRESS:12641 GARDEN WAYTELEPHONE:
(951) 305-5308
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 2DATE:
07/12/2024
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:David Adubi-LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to the facility for the purpose of change of ambulatory status. LPA was greeted and granted entrance by the Licensee, David Adubi.

Per the STD850, the ambulatory capacity decreased from four (4) ambulatory to one (1) ambulatory and increased from zero (0) nonambulatory to three (3) nonambulatory on the fire clearance which the request was approved on 04/17/2024.

There is a facility sketch on file with designation of ambulatory status for each room. The licensee was advised that the noted designated capacity/ambulatory status for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for a change of ambulatory status. LPA will update the facility's file and issue a new license stating change in capacity/ambulatory status.

An exit interview was conducted where this report LIC809 was discussed and provided to the Licensee, David Adubi.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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