<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608594
Report Date: 02/24/2022
Date Signed: 02/24/2022 12:29:55 PM


Document Has Been Signed on 02/24/2022 12:29 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 ELDERLY, LLCFACILITY NUMBER:
197608594
ADMINISTRATOR:DIANA KENEZFACILITY TYPE:
740
ADDRESS:17241 RAYMER STREETTELEPHONE:
(818) 388-1462
CITY:SHERWOOD FORESTSTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Diana KenezTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:30 A.M. Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz arrived at the facility mentioned above to conduct an unannounced annual inspection. LPAs Martinez and Ruiz were greeted by staff Clara and later met with Administrator Diana Kenez. A physical tour was conducted at 11:45 A.M .of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPAs observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Kitchen appliances observed to be in a need of a cleaning and disinfecting. LPAs reminded staff and Administrator to routinely clean and disinfect high touch surface area and appliances. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at 11:58 A.M. and appear to be functional. Fire extinguisher has a service date of 10/05/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 74.0 F. Residents Rooms: All 6 of the residents’ bedrooms were toured and appear to be clean and properly furnished. LPAs observed additional bedding and linens sufficient for all of the residents. Trash cans in residents’ bedrooms did not have tight fitting lids. LPAs stated they needed to add tight fitting lids to the trash cans. Bathrooms: LPAs observed all bathrooms to have grab bars and non-skid mats. At 12:00 p.m. the hot water was tested and measured at 114.6 F. There are 3 bathrooms in the facility in which two (2) are designated for resident use. Garage: There is an attached garage and is being used for additional storage and for a staff room. There is a separate laundry room that leads into the garage. Outside areas: LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1