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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530115
Report Date: 07/25/2023
Date Signed: 07/25/2023 02:17:09 PM

Document Has Been Signed on 07/25/2023 02:17 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:MOUNT ZION ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
365530115
ADMINISTRATOR:ADUBI, DAVIDFACILITY TYPE:
735
ADDRESS:13865 GOLDFINCH CTTELEPHONE:
(973) 336-1395
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
07/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:David Adubi-AdministratorTIME COMPLETED:
02:22 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator David Adubi who was accompanied by two (2) background clearance staff, Chinenye Oluoha and Collet Oluoha. The fire clearance was approved on 4/19/2023 for four (4) ambulatory clients.

The facility has four (4) bedrooms, two and half (2.5) bathrooms, one (1) staff office, kitchen, dining room, living room, family room with fireplace, laundry room, backyard with gazebo, and attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 108.4 degrees F. The refrigerator was measured at 43 degrees F and the freezer was measured at 0 degrees F. There was a locked and secured cabinet where medication and sharps will be stored inside a locked box. There was also non-perishable food inside the pantry and perishable food inside the refrigerator/freezer.

Staff Office: There is a safely locked and secured filing cabinet where clients and staff files are going to be stored.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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 2
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: MOUNT ZION ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 365530115
VISIT DATE: 07/25/2023
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Laundry Room/ Garage: The laundry room is near the entry to the garage. The chemicals and laundry soap were safely locked in this room.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Backyard: There are no bodies of water in the backyard. There is a gazebo with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There were two (2) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has no land line and telephone for clients use.

Pre-Licensing is incomplete and the following deficiency requires to be resolved by 08/01/2023 at 09:00 AM:

An active land line and working telephone.



An exit interview was conducted, and this report was discussed and provided to Administrator, David Adubi.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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