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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601494
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:12:23 PM

Document Has Been Signed on 10/21/2024 01:12 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MT. ZION HOME FOR THE ELDERLYFACILITY NUMBER:
015601494
ADMINISTRATOR/
DIRECTOR:		SABADERA, RESTITUTOFACILITY TYPE:
740
ADDRESS:32655 ALMADEN BLVDTELEPHONE:
(510) 475-5622
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 2DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Restituto Sabadera, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/21/2024 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Plan of Correction (POC) visit from Annual Inspection visit on 04/14/24 and POC visit on 05/23/24 which resulted in civil penalties that were assessed. LPAs met with Licensee/Administrator, Restituto Sabadera and gave reason for visit.

During the POC visit LPAs toured the backyard and observed that the yard was cleaned up and the items that were located under the gazebo was cleared.

Deficiency cleared:

CCR 87303(a)

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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