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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607017
Report Date: 04/01/2025
Date Signed: 04/01/2025 01:50:04 PM

Document Has Been Signed on 04/01/2025 01:50 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,FACILITY NUMBER:
197607017
ADMINISTRATOR/
DIRECTOR:		MA MONA LIZA DUBRIAFACILITY TYPE:
740
ADDRESS:8821 ZELZAH AVENUETELEPHONE:
(818) 885-0999
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
04/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Licensee, Diana KenezTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 04/01/25, at 09:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Maria Agustin and disclosed the purpose of the visit. The Licensee was called and arrived fifteen (15) minutes later.

LPA asked for the census, resident, and staff files. The facility tour started 11:05am Temperature of facility wall thermostat is observed and set to be 70 and 70 degree Fahrenheit. There are two (2) thermostats. One (1) in each hallway.

Medications-The medication is kept in two (2) areas. One (1) area is in one (1) of the cabinets in the kitchen area, secured and inaccessible to residents and the rest of the medication is kept in another closet area in one (1) of the staff rooms also inaccessible to residents. The first aid kits is stored in the medication closet in the staff room locked.

There is a backyard which has outdoor furniture for outdoor activities available for six (6) residents. There is a pool that is fenced and locked inaccessible to the residents.

Living and dining room furniture is accessible for six (6) residents. There is a television, another telephone line and enough seating for six (6) residents. Furniture was observed to be in good condition and there is a fireplace with a covering, inaccessible to the residents. There is one (1) carbon monoxide detector against the wall. The smoke detectors are hardwired and interconnected and were tested. They were functional.

LIC 809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 RESIDENTIAL FACILITY FOR ELDERLY,
FACILITY NUMBER: 197607017
VISIT DATE: 04/01/2025
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Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. There are three (3) refrigerators in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area fully charged and expires October 2025. The washer and dryer, toxins, and extra hygiene are located in one (1) of the cabinets in the kitchen area inaccessible to the residents locked and secured. There is one (1) phone line located in the kitchen area. The other phone line is located in the living room on top of one (1) of the desks.

Bedrooms: There are eight (8) bedrooms with two (2) separate hallways. There are six (6) resident bedrooms and two (2) staff bedrooms. Three (3) of the resident rooms have their private bathroom and are single occupied. The other two (2) bedrooms are also single occupied and have access to one (1) of the private bathrooms. All six (6) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperature of the water are within regulations. They between 114-116 degree Fahrenheit. In between the rooms there is a pantry that has extra linen.

The garage is attached to the house and has extra hygiene and incontinence for the residents. There is an entrance leading from one (1) of the staff rooms to the garage area. There is also seating in the front entrance of the facility for staff and residents.

Administrative: The Insurance plan is updated, disaster plan, YES sign, evacuation plan sketch and administration certificates are against the wall at the entrance of the facility. On your right hand side of the entrance of the facility, there is a pantry that is locked and inaccessible to the residents that contains extra toxins at the entrance of the facility on your right hand side. The Ombudsman sign is located in the kitchen against the wall. The infection control is in a binder. The fire drill was recently conducted on 03-20-2025 and is also in a binder. The facility has a signal system.



An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
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