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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608994
Report Date: 10/24/2024
Date Signed: 10/25/2024 10:04:08 AM


Document Has Been Signed on 10/25/2024 10:04 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EVENING GRACE ASSISTED LIVING NORTHRIDGEFACILITY NUMBER:
197608994
ADMINISTRATOR:KENEZ, PAULFACILITY TYPE:
740
ADDRESS:9611 CORBIN AVETELEPHONE:
(818) 717-1840
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mariza Dulfo ChuaTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with backup Administrator Mariza Dulfo Chua and explained the reason for the visit.
At approximately 12:35 pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The fire extinguisher is located in the kitchen with a purchase date of 10/13/2024.

Laundry Area: Laundry area is located at the far end of the kitchen. Appliances were observed to be in good repair. All the toxins, cleaning solutions, and disinfectants are locked in the pantry across from the washer and dryer.

Bedrooms: The facility has seven (7) bedrooms. There were six (6) bedrooms designated for residents' use. One(1) bedroom is designated for staff. All Six (6) residents' bedrooms are designated for private use. All residents' bedrooms were properly furnished with appropriate bedding and linens with sufficient lighting. LPA observed there is a carbon monoxide detector that functions properly installed in the hallway between resident rooms. LPA tested smoke alarms and they were interconnected and battery-operated.

Bathrooms: There are three (3) bathrooms: one (1) bathroom in the hallway near the front of the house, one (1) bathroom at the far end of the kitchen, one (1) in the private bedroom, and unused half bath as broom/mop/bucket holding area. Each bathroom has a posted “wash your hands” sign and the following items are available: hand soap, paper towels, and trash cans. The hot water temperature was measured at 116.6. No cleaning supplies or hazardous items were present in each bathroom during the inspection.

(Continue on 809C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVENING GRACE ASSISTED LIVING NORTHRIDGE
FACILITY NUMBER: 197608994
VISIT DATE: 10/24/2024
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Medications: Medication and Medication Records were reviewed for proper documentation.

Temperature: The facility maintains a comfortable temperature of 77 degrees Fahrenheit

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Medications were locked in a closet near the front door across from the kitchen. Medications were observed to be locked and inaccessible to residents.
Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a covered patio and a large gazebo with a table and chairs for residents to use in the backyard. The patio furniture was observed to be in good repair.

Garage: The garage is used for storage boxes, and equipment, and has an extra deep freezer for meats and poultry.

Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that LIC 601, LIC 603, and LIC 625 are missing from R1, R2, R3, and R4 files. LPA also observed that R3 doesn't have an updated physician report for this year.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms. LPA observed that S1 and S2 have expired CPR certificates.

Exit interview conducted, citations issued, appeal rights given and copy of this report signed and delivered.




SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/25/2024 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: EVENING GRACE ASSISTED LIVING NORTHRIDGE
FACILITY NUMBER: 197608994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1 and S2 have expired CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will submit CPR certificates by the POC date.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. R1, R2, R3, R4 have no a pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will submit pre-admission appraisals by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/25/2024 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: EVENING GRACE ASSISTED LIVING NORTHRIDGE
FACILITY NUMBER: 197608994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R3 has not updated physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will submit R3's physician report by the POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R1, R2,R3 and R4 have no appraisal needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will submit appraisal needs and services plans by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4