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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804153
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:15:44 PM

Document Has Been Signed on 05/15/2023 02:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ZION'S HOMEFACILITY NUMBER:
486804153
ADMINISTRATOR:APOSTOL, KATHERINEFACILITY TYPE:
735
ADDRESS:1965 CLYDE JEAN PLACETELEPHONE:
(650) 333-9568
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
05/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Iris Baratas
Prospective Administrator, Katherine Apostol.		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Zion's Home for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Licensee, Iris Baratas and Prospective Administrator, Katherine Apostol. The Fire Clearance was granted for 3 Ambulatory clients with 1 Non-Ambulatory and 0 Bedridden clients. Administrators Certificate (Administrator Certificate #: 6038007735 was issued on 12/08/2021 with an expiration 12/07/2023) was reviewed by the LPA during the Pre-Licensing Inspection and found to be valid and appropriate. A copy of the Administrators First Aid Certificate and CPR was valid and expires on 01/28/2025. A copy of the Surety Bond for the facility is retained in the facility records and observed during the Pre-Licensing inspection.

LPA, Licensee and Prospective Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguishers were found to be last charged on April 2023. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 107 degrees in 1 of 1 clients bathrooms and 107 degrees in 1 of 1 staff bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. Sample food menu was observed. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel Records, medication will be locked and in separate cabinets. Hazardous items and toxins are kept locked in the garage and inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is an outdoor space for activities with a shaded area. During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA reviewed the Mitigation Plan with the facility during the Pre-Licensing inspection. Emergency Disaster plan was discussed with the Licensee and the Prospective Administrator. All staff will be trained in the Emergency Disaster and PPE training. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZION'S HOME
FACILITY NUMBER: 486804153
VISIT DATE: 05/15/2023
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LPA was advised that the facility is in the process of obtaining a Emergency Generator.

Component III was discussed in detail with the Licensee and Prospective Administrator.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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