<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425792
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:39:39 PM

Document Has Been Signed on 10/23/2024 01:39 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:ZAB HOME LLC, THEFACILITY NUMBER:
366425792
ADMINISTRATOR/
DIRECTOR:		BALGJIAN, NARINEFACILITY TYPE:
735
ADDRESS:11495 SHAHAPTAIN AVE.TELEPHONE:
(760) 244-4877
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 3DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Melanie BalgjianTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Melanie Balgjian, Facility Manager and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (3). The facility is a certified Inland Regional Center (IRC) vendor. During today's visit there was one client present and two clients were attending program.

LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating within the capacity approved by Community Care Licensing. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. Outdoor activity space is shaded and gated. The facility is equipped with smoke/carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, sufficient personal hygiene products and telephone service. Client bedrooms were equipped with beds, nightstands, chairs, storage space and sufficient lighting. Client bathroom equipment was fully operational. The hot water in client bathrooms tested at 109 degrees F. LPA observed no emergency hallway lights leading to non-private bathrooms. A deficiency cited. Sharps, disinfectants and cleaning supplies were kept stored in a locked cabinet and locked container. The Administrator's certification, facility's liability and surety bond are current.

Food Service: The facility’s dining areas and kitchen were maintained clean. The facility has sufficient non-perishable and perishable food for clients in care. The facility’s freezers and refrigerators were fully operational.

Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked cabinet.

Personnel/Client Records: Staff records were reviewed for health screenings, criminal record clearances, employment history and first aid/CPR training certifications and observed to be complete. Client records were reviewed for admission agreements, IRC placement documentation, medical assessments, needs and service plans, and personal/incidental logs. Review of all three (3) client records reveals clients do not have a current and complete annual Individual Personal Plan (IPP) on file for review.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 4
Document Has Been Signed on 10/23/2024 01:39 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/23/2024 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ZAB HOME LLC, THE
FACILITY NUMBER: 366425792

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by not maintaining nightlights in hallways leading to nonprivate client bathrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
The Licensee shall provide to the Licensing Agency proof of night lights by POC due date.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a current and complete IPP on file for all three clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
The Licensee shall submit to the Licensing Agency current 2024 IPP for all three clients by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ZAB HOME LLC, THE
FACILITY NUMBER: 366425792
VISIT DATE: 10/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of all three (3) client records reveals clients do not have a current and complete annual Individual Personal Plan (IPP) on file for review. The facility manager stated that IRC is scheduled to conduct a review on 10/30/24. A deficiency cited.

Deficiencies were cited and a technical advisory was issued per Title 22 of the California Code of Regulations. An exit interview was conducted, where reports LIC809/LIC809-C/LIC809-D/LIC9102TA were provided. Copies of the reports with appeal rights were provided to the facility manager at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4