197608594-2-13-2024-31-AS-GSAO-D2EQY3-20240213113429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608594
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:34:37 AM

Document Has Been Signed on 02/13/2024 11:34 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EVENING GRACE RES. FACILITY FOR ELDERLY, LLC		FACILITY NUMBER:	197608594
ADMINISTRATOR:	CLARA EMNAS		FACILITY TYPE:	740
ADDRESS:	17241 RAYMER STREET		TELEPHONE:	(818) 388-1462
CITY:	SHERWOOD FOREST	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Clara Emnas		TIME COMPLETED:	11:55 AM

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On 02/13/24 at 8:50 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Administrator Clara Emnas and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 10:05 AM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your right-hand side, next to the refrigerator. It is fully charged. There is a telephone line on one of the counters in the kitchen. There is extra, food in the kitchen pantries. The sharps are locked and inaccessible to the residents in one of the lower cabinets. The medication and first aid are locked and inaccessible on your right-hand side of the kitchen where there is a hallway by the entrance of a resident’s room. On top of the medication cabinet are binders: Disaster Emergency Manual, Infection Control and Fire Drill. There is also a carbon monoxide against the wall. The garage can be accessed from this area. The garage is attached to the house.

The garage is where the toxins/chemicals are kept. There is one washer and dryer. There is also a partition for staff to rest/sleep.

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: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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 ELDERLY, LLC	FACILITY NUMBER: 197608594
	VISIT DATE: 02/13/2024

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The dining area/living room area is located next to the kitchen where there is enough seating for the residents and the staff. There is a large television and there is also internet access. This dining hall leads to the backyard.

Outside/Backyard: The outside/backyard has furniture for residents with proper seating. The facility has a signal system. The facility does not have a pool and/or bodies of water.

Bedrooms: There are six (6) bedrooms and three (3) bathrooms. All the bedrooms are single, occupied. There are two (2) bedrooms that have a shared bathroom. The other three (3) bedrooms have a shared bathroom down the hallway and one (1) of the bedrooms has a private bathroom. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 114–115 degree Fahrenheit.

The carbon monoxide and smoke detectors are located throughout the facility and are operable.

Administrative: There is no annual fee that is due right now. The surety bond is updated. At the entrance of the facility there is the YES sign, facility sketch, administrator certificate, Ombudsman, and emergency disaster plan against the wall.

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: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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