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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530115
Report Date: 08/01/2023
Date Signed: 08/01/2023 09:14:01 AM

Document Has Been Signed on 08/01/2023 09:14 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: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:
08/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Collet Oluoha- LicenseeTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced follow up Prelicensing visit 08/01/2023. This is an announced second Pre-Licensing visit conducted with Licensee, Collet Oluoha who assisted in the tour of inside and outside of facility and the evaluation. The follow up visit was made to confirm that the correction has been made.

An active land line and working telephone has been corrected. Facility working telephone number is (760) 255-3734.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure.

Licensee will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Licensee, Collet Oluoha.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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