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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804153
Report Date: 09/25/2025
Date Signed: 09/25/2025 10:49:23 AM

Document Has Been Signed on 09/25/2025 10:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ZION'S HOMEFACILITY NUMBER:
486804153
ADMINISTRATOR/
DIRECTOR:		LOURDES V SOLLERFACILITY TYPE:
735
ADDRESS:1965 CLYDE JEAN PLACETELEPHONE:
(650) 333-9568
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: DATE:
09/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:LOURDES SOLLER-administratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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At approximately 10:00 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a case management at Zion's home. Zion's home is level 4i Adult Residential Care Facility (ARF) with four (4) clients in care. During today's visit, three (3) of four (4) clients were away at day programming.

The purpose of today's case management was to follow up on a self-reported Special Incident Report (SIR) received by Community Care Licensing (CCL) on 09/19/2025 about an incident that took place between two (2) clients on 09/17/2025 in which client 2 (C2) allegedly hit client 1 (C1) on the right side of his head, "3-4 times" over food that C2 thought C1 was stealing out of the facilities refrigerator; police were called. No bruising, swelling or redness was observed by staff on C1 and the police directed both clients to stay away from each other. C2 was advised by staff that all food in the facility are for all clients.

Separately, on 01/03/2025 CCL received an SIR which indicated that on 12/30/2024, C2 felt that C1 was dis-respecting the facility manager and came out of their room, to hit C1 on the left side of the face, "no visible or major injuries" were noted by the staff at the time. Then on 07/23/2025 CCL received a 3rd SIR indicating that on 07/18/2025, C2 suddenly grabbed and attacked C1, again thinking that C1 was eating C2's personal food; on that occasion police were also called and although no arrests were made, police advised C2 and C1 to "stay away from each other for the time being"

In speaking with staff today, C2 often purchases their own food and it is suspected that C2 feels like C1 is taking their foods out of the refrigerator. Staff reported this most recent incident with C2's psychiatrist and report that C2 has an appointment for a neuropsych evaluation this afternoon at 2:00PM. C2's LIC625 indicates they are having regular visits with MDs and psychiatrists to "ensure proper medicine management" and C2 is currently on four (4) meds for mood/behavior/agitation stabilization medicines.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZION'S HOME
FACILITY NUMBER: 486804153
VISIT DATE: 09/25/2025
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Continued from LIC809

C2 has MD orders in their file indicating "call crisis center (988) or crisis resources if needed or if in danger to self or others". LPA has recommended that staff post this 988 number prominently in the facility or staff room, such as to allow all staff to have quick access to this number when needed.

In addition, we spoke about methods the facility might use to earmark portions of the facility refrigerators for C2 to reduce suspicion by C2 that others in the home are using their food.

Staff was encouraged to speak with C2's doctors and work as a facility staff to reduce the incidents of aggressive outbursts by C2.

LPA conducted interviews, observed records and spoke with staff

No deficiencies are being cited today.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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