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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607451
Report Date: 08/18/2022
Date Signed: 08/18/2022 12:37:20 PM


Document Has Been Signed on 08/18/2022 12:37 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EVENING GRACE RES. FACILITY FOR THE ELDERLY LLC.FACILITY NUMBER:
197607451
ADMINISTRATOR:MA MONA LIZA DUBRIAFACILITY TYPE:
740
ADDRESS:8811 ZELZAH AVENUETELEPHONE:
(818) 885-0999
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 6DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ma Mona Liza Dubria TIME COMPLETED:
12:45 PM
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On 08/18/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with Licensee Diana Kenez and Administrator Ma Mona Dubria. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 12:00 p.m and the following were observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medications are centrally stored in a locked closet in the kitchen area. Chemicals are stored underneath the sink in a lock cabinet. Smoke detectors/carbon monoxide are located throughout the facility. Facility has fire sprinklers throughout the home. Smoke detectors and carbon monoxide detectors were tested at approximately 12:10 p.m and were observed to be functional. Fire extinguisher has a purchase date of 10/05/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a temperature of 79 F. Resident Rooms: Facility has eight (8) bedrooms which of six (6) are designated for resident use. Facility has two live-in staff. All eight (8) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are four (4) bathrooms in the facility of which three (3) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 107.2 F, which is in regulation. All trash cans located in the bathrooms have tight fitting lids. (Continue on 809-C)

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVENING GRACE RES. FACILITY FOR THE ELDERLY LLC.
FACILITY NUMBER: 197607451
VISIT DATE: 08/18/2022
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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a back house on the grounds that is unoccupied at the moment. There are no bodies of water.

No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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