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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607451
Report Date: 09/12/2023
Date Signed: 09/13/2023 07:43:39 AM


Document Has Been Signed on 09/13/2023 07:43 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.ASC, 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: 5DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Diana KenezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with Licensee Diana Kenez and informed her the reason of the visit.

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. All clients and staff are vaccinated. New admits and new staff hire must have a negative COVID test, but does not have to be vaccinated. 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. Facility has extra freezer and refrigerator stocked with food. Food storage and preparation areas are clean. 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. First aid kit checked. Facility has fire sprinklers throughout the home. Smoke detectors and carbon monoxide detectors were tested and operating correctly. Fire extinguisher fully charged. Common Areas: All common areas were observed to be clean and properly furnished. Resident Rooms: Facility has eight (8) bedrooms which of six (6) are designated for resident's and (2) for staff. All bedrooms were 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; and bathrooms were clean. The hot water was tested and measured.

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.

Record review: LPA observed resident and staff files; all required documents observed; including updated training records.

No deficiencies cited. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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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