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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530115
Report Date: 08/28/2024
Date Signed: 08/28/2024 10:51:15 AM

Document Has Been Signed on 08/28/2024 10:51 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/
DIRECTOR:		CONSTANCE A ODUDUFACILITY TYPE:
735
ADDRESS:13865 GOLDFINCH CTTELEPHONE:
(973) 336-1395
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Constance Odudu-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) MIchelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee Collet Oluoha, Chinenye Oluoha and Administrator Constance Odudu, and introduced self and stated purpose of the visit. LPA was informed that there are no clients in care.

The facility has 4 bedrooms, 2.5 bathrooms, kitchen, dining area, family room, living room, laundry room, attached garage, and backyard. The facility is pending vendorization by Inland Regional Center. LPA completed a walk through of facility and review of records.

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 82 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 111.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit will be in secure cabinets and inaccessible to clients. The facility had emergency kits for future clients in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.

Food Service: Non-perishable and perishable food supply will be purchased when vendorization is approved. Dishes, cups, and utensils were also stored properly. Emergency food and water were observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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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: 08/28/2024
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Yards/Outside: LPA observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed Licensee and Administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to the Administrator, Constance Odudu.

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

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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