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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804153
Report Date: 04/16/2026
Date Signed: 04/16/2026 12:08:45 PM

Document Has Been Signed on 04/16/2026 12:08 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
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: 4DATE:
04/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Lourdes SollerTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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At approximately 9:50 AM Licensing Program Analyst (LPA), Star Stevenson arrived unannounced to conduct a required 1-Year Annual inspection. LPA was greeted by Administrator Lourdes V Soller.

At approximately 10:00 AM LPA and Lourdes Soller toured the facility. LPA observed the facility to be clean, without odors and all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2026. All combination smoke and carbon monoxide detectors were tested and found to be operational and centrally wired. In addition the facility has a number of individual redundant carbon monoxide detectors in each client's rooms. Last Fire/Emergency Drill was conducted for all shifts on 04/07/2026. Hot water temperature measured at 106.2 degrees F in two (2) of 2 client bathrooms, which is within acceptable range of 105-120 degrees. Hazardous items and toxins are kept locked in the garage and/or drawers and are inaccessible to clients in care.

Sample food menu was observed as well as large activity/schedule calendar. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. Leftover foods/meats were noted to be labeled with the date they were removed from commercial packaging.

LPA noted ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware.
Facility was observed to have emergency generator, extra water, go emergency bags for each client, large and multiple smaller 1st aid kits. Clients have a treadmill, corn hole, TV, games, shaded and sun areas available to them.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2026
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: 04/16/2026
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Continued from LIC809
Two couches, a small fold-away bed and two (2) removable TV dinner tables, along with blankets were observed in the garage with laminate flooring and Administrator was told to ensure that no staff should be living or sleeping in a garage not indicated by the fire department as a bedroom or sleeping area; in an area that has no smoke or carbon monoxide detectors or firewalls/doors.

At approximately 10:45 AM Four (4) of 4 client records were observed to be complete.

At approximately 11:00 AM Five (5) staff records were evaluated and three (3) of 3 staff members present had complete files. Staff member S1 and staff member S2 were said to "work part time at Zion's home" by Administrator and were listed on Zion's home LIC500 but were not registered in Guardian. Both S1 and S2 are known to work at a sister facility and have record of LIC508 and fingerprint/criminal clearance. Licensee is reminded of the requirement to have ALL staff that are on the LIC500 Personnel Report registered with Guardian. S1 & S2 did have all other records in place for Zion's Home as required by Title 22 regulations. Licensee is asked to submit evidence of S1 and S2 registered in Guardian to Zion's home by 04/26/2026.

At approximately 11:00 AM P&I monies were observed to be accounted for.
A spot check of medicines were observed to be centrally stored and locked and well documented.

LPA obtained copies of an updated LIC500 Personnel Roster, LIC610D Emergency Disaster Plan and Updated Copy of Surety Bond for the facilities files.

No deficiencies are cited today

Report was reviewed with Administrator whose signature here indicates receipt.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC809 (FAS) - (06/04)
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