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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804153
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:23:40 PM

Document Has Been Signed on 05/21/2024 12:23 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/
DIRECTOR:		APOSTOL, KATHERINEFACILITY TYPE:
735
ADDRESS:1965 CLYDE JEAN PLACETELEPHONE:
(650) 333-9568
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Lourdes Soller, Lead StaffTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Zion's Home for the purpose of conducting a 1-Year Annual inspection. LPA was greeted at the door by staff. Lourdes Soller, Lead Staff arrived within 15 minutes.

LPA and Lourdes Soller toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguisher was found to be last charged on April 5, 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of inspection. Last Fire Drill was conducted for all shifts on 5/2/2024. Hot water temperature measured at 106 degrees F in 2 of 2 client bathrooms, which 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 supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware. 4 of 5 Client Records were complete, with one waiting on an updated physician's report and 5 Personnel Records were inspected and found to be complete. Medications and client files are locked in separate cabinets in locked medication closet . Hazardous items and toxins are kept locked in the garage and inaccessible to clients in care. Facility has an outdoor space for activities with a shaded area. Common areas provide comfortable seating and activities to promote socialization.

No deficiencies cited at the time of this inspection.

Exit interview conducted with Lourdes Soller, Lead Staff.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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