197608994-9-6-2022-31-AS-TSMH-CHZRHC-20220906130206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608994
Report Date: 09/06/2022
Date Signed: 09/06/2022 01:02:14 PM

Document Has Been Signed on 09/06/2022 01:02 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 ASSISTED LIVING NORTHRIDGE		FACILITY NUMBER:	197608994
ADMINISTRATOR:	KENEZ, PAUL		FACILITY TYPE:	740
ADDRESS:	9611 CORBIN AVE		TELEPHONE:	(818) 717-1840
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	09/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mariza Chua		TIME COMPLETED:	01:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Annual infection Control visit to this facility at 10:10 am. LPA Smiths’ temperature taken upon entry and Covid symptoms questions asked by House Manager Mariza Chua. LPA informed staff the purpose of this visit. The administrator was called and arrived later. House manager was authorized to sign the report.

LPA conducted a tour at 10:55 AM of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living room and dining area and observed adequate seating for residents. Staff confirmed there are six (6) clients in the home. The living area had furnishings, sufficient lighting and the area was clean.

Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher is located in kitchen next to refrigerator and observed to be charged.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed with juice in 2^nd refrigerator. The freezer is stocked with meats.

Medications are were locked in a closet near front door across from kitchen. Medications observed to be locked and inaccessible to clients. LPA observed stocked first aid kit stored in medication closet

Sharps observed to be locked in bottom cabinet in kitchen and inaccessible to clients. All the toxins, cleaning solutions and disinfectants are locked in pantry across from washer and dryer. Laundry area located at far end of kitchen. Appliances observed to be in good repair.

(Cont. to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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 ASSISTED LIVING NORTHRIDGE	FACILITY NUMBER: 197608994
	VISIT DATE: 09/06/2022

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(Cont. form 809)

There are seven (7) bedrooms; Six (6) for clients and one (1) for staff. A tour of the client’s bedrooms, bathrooms, personal accommodations, and common areas (all resident bedrooms toured had the required furniture for residents’ comfort and safety). Common areas were observed for the ability to safely serve the needs of residents, skid materials, grab bars, and comfortable temperatures. LPA observed a sufficient supply of linens in each client’s room/closet.

There are three (3) bathrooms: one (1) bathroom in hallway near front of house, one (1) bathroom at far end of kitchen, one (1) in private bedroom and unused half bath as broom/mop/bucket holding area. Each bathroom has posted “wash your hands” sign and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 112.7, 113.4, and 115.6-degrees Fahrenheit.

Garage used to store PPEs, equipment and deep freezer that is stocked with additional meats and poultry. There is a covered patio and a large gazebo with table and chairs for clients use in the backyard. Patio furniture observed to be in good repair. LPA obtained copy of infection control plan.

There was no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report was given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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