565850325-3-16-2023-29-AS-ZCHN-CPZ35X-20230316175729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850325
Report Date: 03/16/2023
Date Signed: 03/16/2023 05:58:27 PM

Document Has Been Signed on 03/16/2023 05:58 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WISDOM & GRACE SENIOR CARE INC.		FACILITY NUMBER:	565850325
ADMINISTRATOR:	ALVIZURES, WALFRE A.		FACILITY TYPE:	740
ADDRESS:	4031 APRICOT RD.		TELEPHONE:	(818) 335-2355
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	03/16/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Walfre Alvizures		TIME COMPLETED:	05:45 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	Licensing Program Analyst (LPA) arrived to this property for a pre-licensing inspection. The LPA met with applicant Walfre Alvizures. This is a change of ownership application from A Bradley House (#565800622) to Wisdom & Grace Senior Care Inc. (#565850325). Applicant successfully completed Component II on 01/20/2023 and Component III during todays visit. The LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. There are five (5) bedrooms for residents (one (1) shared room and four (4) private rooms). Lighting in the rooms appeared adequate; set up with beds, night stands, lamps, chests of drawers, chairs and closet space. There are three (3) bathrooms equipped with nonskid surfaces/mats and operable fixtures. Grab bars were observed in the bathrooms. In addition, there is a separate wing which has three (3) rooms and two (2) bathrooms. Submitted facility sketch identifies the separate wing as resident rooms. Applicant stated that the separate wing is not for residents use. Applicant was informed to update the facility sketch to accurately reflect the separate wing use. Emergency exiting plans/sketch observed posted; all other required postings posted near the kitchen/dining area of the facility. MEDICATIONS: Medications are in a locked cabinet adjacent to the kitchen. First aid kit observed complete. FILES: Staff and resident files are stored secured in a cabinet. The laundry area is set up adjacent to the kitchen. Laundry detergent and chemicals are stored inaccessible in a cabinet. The exterior passageways were clean and clear of any obstructions. There is a jacuzzi on the premises which is made inaccessible to residents.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WISDOM & GRACE SENIOR CARE INC.	FACILITY NUMBER: 565850325
	VISIT DATE: 03/16/2023

NARRATIVE

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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The facility smoke alarm system is hard wired; two smoke detectors observed to be dual smoke and carbon monoxide detector; all were operable at the time of the visit. There is a fireplace in the dining area, which is appropriately screened. The fire extinguisher was fully charged and last serviced 03/13/2023. There is a functioning telephone on the premises. Kitchen knives are stored locked and inaccessible in the closet in the hallway. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food.

Applicant needs to provide/update facility sketch to correct the adjacent separate wing use. What is submitted is not accurate. Once the updated sketch is received and reviewed that the Centralized Application Bureau Analyst will notify the applicant when the license has been approved.

Exit interview conducted and report issued..

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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