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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701460
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:16:12 PM

Document Has Been Signed on 10/15/2024 03:16 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ZINNIA NURTURING RESIDENCE 1 LLCFACILITY NUMBER:
392701460
ADMINISTRATOR/
DIRECTOR:		DE LA PENA, MARY JANEFACILITY TYPE:
735
ADDRESS:3005 ZINNIA WAYTELEPHONE:
(916) 525-5919
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 4CENSUS: DATE:
10/15/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Mary Jane De La Pena & Anabella OlasoTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care):
COMP II Participants: MaryJane Dela Pena (C) & Anabella Olaso (A)
Interview Method: Telephone interview

On October 15, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Medication/Activities/Day Program

3. Staffing requirements & Training

4. Pre Licensing home readiness

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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