197607451-7-2-2024-31-AS-GSAO-D6STMM-20240702145123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607451
Report Date: 07/02/2024
Date Signed: 07/02/2024 02:51:52 PM

Document Has Been Signed on 07/02/2024 02:51 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 RES. FACILITY FOR THE ELDERLY LLC.		FACILITY NUMBER:	197607451
ADMINISTRATOR:	MA MONA LIZA DUBRIA		FACILITY TYPE:	740
ADDRESS:	8811 ZELZAH AVENUE		TELEPHONE:	(818) 885-0999
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 3	DATE:	07/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Diana Kenez		TIME COMPLETED:	03:05 PM

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On 07/02/2024 at 11:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with caregiver Evelyn Sarmiento. Caregiver Evelyn Sarmiento called the administrator, Diana Kenez and they arrived about ten (10) minutes later. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 12:45 PM.

Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. It has a large television and enough seating for residents and staff. The facility maintains a comfortable temperature at 77 degrees Fahrenheit. There is a fireplace that is covered and inaccessible to the residents.

Bedrooms: All eight (8) bedrooms are single, occupied. There are six (6) resident bedrooms and two (2) staff bedrooms. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room.

Bathrooms: There are four (4) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 112 degrees Fahrenheit and 115. The showers have non-slip bathmats and grab bars.

Medications were kept in a locked pantry in the kitchen. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the same pantry in the kitchen.

809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 RES. FACILITY FOR THE ELDERLY LLC.	FACILITY NUMBER: 197607451
	VISIT DATE: 07/02/2024

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Kitchen Area: LPA inspected the kitchen area. There are two (2) refrigerators and one (1) freezer which were clean and in good operation. Knives and sharp objects were kept stored and locked in a cabinet located in the kitchen on your right-hand side bottom cabinet inaccessible to the residents. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet. There are several cabinets filled with extra food. There is one (1) fire extinguisher fully charged and expires 05/2025. There are chemicals under the sink locked and inaccessible to the residents. There is also hygiene in one (1) of the cabinets locked and inaccessible to the residents.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There are also ramps provided for the residents. The washer and dryer are located outside and there is an entrance to the garage. There is a back house on the grounds that is unoccupied at the moment and is not part of the facility. LPA was able to tour it.

The carbon monoxide and the smoke detector were tested, and they were operable. There is a signal system and fire sprinklers throughout the house.

Garage: The garage is detached from the facility and is used for parking.

Administration: The Infection control was reviewed. The Liability Insurance is updated. There are Covid 19 signs throughout the facility, the Ombudsman sign is located at the entrance of the facility against the wall on your left-hand side. There is a YES sign 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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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