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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607821
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:27:04 AM

Document Has Been Signed on 08/13/2024 11:27 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ZION RESIDENTIAL CAREFACILITY NUMBER:
197607821
ADMINISTRATOR/
DIRECTOR:		JENNETH AGUILARFACILITY TYPE:
740
ADDRESS:16654 SAN FERNANDO MISSION BLVTELEPHONE:
(818) 620-2202
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 1DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jenneth Aguilar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 08/13/24, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Ernesto Dizon. Jenneth Aguilar the administrator was called and later arrived.

LPA asked for the census, resident, and staff files.

The facility has been licensed as a Residential Care Facility for the Elderly. The physical plant was toured inside and outside at 10:25 am.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one (1) refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one(1) of the cabinets on your right-hand side of the kitchen. The medication cart is kept in the kitchen area locked and secured. There is one (1) washer and dryer kept in the kitchen area. The fire extinguisher was observed to be full and dated February 20, 2024.

Living/Dining Room: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The dining room area has six (6) seats for residents and a television. The living room area has proper seating and a television. The facility temperature is at 75 degrees Fahrenheit. There is a fireplace that is covered.

No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were tested and operational. The facility has a current telephone landline and internet access.



LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ZION RESIDENTIAL CARE
FACILITY NUMBER: 197607821
VISIT DATE: 08/13/2024
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Bedrooms: Facility has six (6) bedrooms and were toured. The bedrooms are fully furnished with proper lighting and bedding. Four (4) of the bedrooms are single, occupancy. One (1) of the bedrooms can be used as a shared and has a private bathroom. There is one (1) staff bedroom currently occupied by staff. There is another bathroom for staff and residents use. There are two (2) cabinets that have extra linen, PPE’s and incontinence. The bathrooms had proper grab bars, non-skid mats. Bathroom contained a trash can with tight-fitting lid. Hot water was tested and measured within regulations of 110.

Outside/Backyard: The chemicals/toxins are kept in a storage shed outside locked and secured. The garage is detached from the house with an extra refrigerator and storage supplies. The outside/backyard has furniture for residents to have proper seating. The facility has a signal system.

There is no bodies of water.

Administrative: There is an annual fee that is due right now of $495.00 due by 09/29/24. The Insurance plan is updated as of 02/12/2024, disaster plan, Resident Rights, licensee certificate, Infection control, Ombudsman, and Facility Sketch are against the wall at the entrance of the facility. There is also a closet at the entrance of the facility.


An exit interview was conducted, no citations() were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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