197607017-5-14-2024-31-AS-GSAO-D59SFJ-20240514135024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607017
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:50:55 PM

Document Has Been Signed on 05/14/2024 01:50 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,		FACILITY NUMBER:	197607017
ADMINISTRATOR:	MA MONA LIZA DUBRIA		FACILITY TYPE:	740
ADDRESS:	8821 ZELZAH AVENUE		TELEPHONE:	(818) 885-0999
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 5	DATE:	05/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mona Dubria		TIME COMPLETED:	02:05 PM

NARRATIVE

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On 05/14/24, at 11:05 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with administrator- Mona Dubria and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff rosters. The facility tour started 11:50 a.m. Temperature of facility wall thermostat is observed and set to be 74 and 73 degree Fahrenheit. There are two (2) thermostats.

Medications-The medication is kept in two (2) areas. One (1) area is in one (1) of the cabinets in the kitchen area, secured and inaccessible to residents and the rest of the medication is kept in another closet area in one (1) of the staff rooms also inaccessible to residents. There first aid kits is stored in the medication closet in the staff room locked.

There is a backyard which has outdoor furniture for outdoor activities available for six (6) residents. There is a pool that is fenced and locked inaccessible to the residents.

The garage is attached to the house and has extra hygiene and incontinence for the residents. There is an entrance leading from one (1) of the staff rooms to the garage area. There is also seating in the front entrance of the facility for staff and residents.

Living and dining room furniture is accessible for six (6) residents. There is a television, another telephone line and enough seating for six (6) residents. Furniture was observed to be in good condition and there is a fireplace with a covering, inaccessible to the residents. There is one carbon monoxide detector against the wall. The smoke detectors are hardwired and interconnected and were tested. They were functional.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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: EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,	FACILITY NUMBER: 197607017
	VISIT DATE: 05/14/2024

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Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. There are three (3) refrigerators in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area fully charged and dated May 2025. The washer and dryer, toxins, extra hygiene and napkins are located in one (1) of the cabinets in the kitchen area inaccessible to the residents locked and secured. There is one (1) phone line located in the kitchen area.

Bedrooms: There are eight (8) bedrooms. There are six (6) resident bedrooms and two (2) staff bedrooms. Three (3) of the resident rooms have their private bathroom and are single occupied. The other two (2) bedrooms are also single occupied and have access to one (1) of the private bathrooms. All six (6) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperature of the water are within regulations. They between 116-118 degree Fahrenheit. In between the rooms there is a pantry that has extra linen.

Administrative: There is no annual fee that is due right now. The Insurance plan is updated, disaster plan, YES sign, evacuation plan sketch and administration certificates are against the wall at the entrance of the facility. On your right hand side of the entrance of the facility, there is a pantry that is locked and inaccessible to the residents that contains extra toxins at the entrance of the facility on your right hand side. The Ombudsman sign is located in the kitchen against the wall. The infection control is in a binder. The facility has a signal system.

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

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