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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530015
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:12:35 PM

Document Has Been Signed on 03/04/2025 12:12 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 ASC, 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: 4DATE:
03/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:David Adubi, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 3/4/2025 at 9:30 AM, Licensing Program Analyst (LPA) Eldin Serrano arrived at the facility unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to an Special Incident Report (SIR) received at the Community Care Licensing Office on 2/27/2025. LPA was greeted by House Manager Breanna Holloway at the front door. LPA introduced self and stated purpose of the visit.

During today's visit, LPA discussed the purpose of the visit to the Licensee David Adubi. LPA did a health and safety check and reviewed client records. LPA Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. LPA observed 4 clients and 4 staffs including the licensee David Adubi. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

No deficiencies were observed during this visit. An exit interview was conducted where this report was reviewed, discussed and then provided to Licensee David Adubi.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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