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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609036
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:51:39 PM


Document Has Been Signed on 10/09/2023 03:51 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EVENING GRACE ASSISTED LIVINGFACILITY NUMBER:
197609036
ADMINISTRATOR:KENEZ, PAULFACILITY TYPE:
740
ADDRESS:17452 TIARA STREETTELEPHONE:
(818) 654-6087
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:6CENSUS: 6DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dianna Kenz- Back up AdministratorTIME COMPLETED:
03:55 PM
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On 10/09/2023 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with back up Administrator Dianna Kenz. A tour of the physical plant was conducted at 10:15 AM. The facility has 2 stories. First floor is for residents and the second is for the live-in staff.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were stored in locked drawers and cabinets. Medications are locked in the kitchen cabinet. Medications observed to be locked and inaccessible to clients. LPA observed fully stocked first aid kit in the kitchen drawer.


Laundry Area: Appliances observed to be in good repair. Laundry room door was locked and thus laundry detergents were inaccessible to residents. LPA observed staff restroom room inside the laundry room.
Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit.
Surrounding Grounds: Entry/exits were observed to be locked. The outdoor area observed to have a covered shaded area for clients. There is no body of water in the facility.
Smoke Alarms and Carbon Monoxide: The fire extinguisher is located in the kitchen, observed to be fully charged and was purchased on 09/07/23. Bathrooms: There were seven (7) bathrooms in the first floor of the facility. Six (6) bathrooms for residents use in private bedrooms. One (1) bathroom for staff located in the laundry room. All bathrooms were clean, properly supplied and had functional fixtures. Water temperatures were 115, 116.1,115.3,118.9,119.3 and 118.6 degrees Fahrenheit. LPA observed cleaning solutions in the bathroom cabinets. Staff immediately took all cleaning solution and locked them in the laundry room. Bedrooms: There were six (6) bedrooms designated for residents' use. All bedrooms are private and clean, properly furnished and had sufficient lighting. Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. (Continue on 809C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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
FACILITY NUMBER: 197609036
VISIT DATE: 10/09/2023
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The garage is currently being used for storage.

Staff Rooms: Staff rooms are located upstairs. No medications are observed in the staff room

Exit interview conducted and a copy of the report and appeal rights were provided. Deficiency was cited on 809D.

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

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2023 03:51 PM - 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
FACILITY NUMBER: 197609036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)


This requirement is not met as evidenced by: Buildings and Grounds. Storage areas for disinfectants, cleaning solutions, and poisons shall be locked.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a bottle of Comet bleach powder and Windex in bathroom cabinets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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The Administrator has agreed to the following:
1. Make sure all cleaning solutions are locked immediately. This was met. The staff locked cleaning solutions during visit.
2. The Administrator has train all staff on locking the cleaning solutions and poisons. Submit training material and staff sign in sheet to LPA by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
LIC809 (FAS) - (06/04)
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