197609036-4-10-2025-31-AS-LNCA-DFLTLS-20250410145002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609036
Report Date: 02/06/2025
Date Signed: 04/10/2025 02:50:13 PM

Document Has Been Signed on 04/10/2025 02:50 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 ASSISTED LIVING		FACILITY NUMBER:	197609036
ADMINISTRATOR/ DIRECTOR:	KENEZ, PAUL		FACILITY TYPE:	740
ADDRESS:	17452 TIARA STREET		TELEPHONE:	(818) 654-6087
CITY:	ENCINO	STATE: CA	ZIP CODE:	91316
CAPACITY: 6		CENSUS: 6	DATE:	02/06/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Maria Elizabeth Sarmiento- designee		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 (LPAs) Leslie Ngo-Castaneda and Angelica Segovia conducted an continuation annual required visit and inspection of the facility. At 1:40 PM Maria Elizabeth Sarmiento who is the staff designee met with LPA, explained the reason for the visit. At 11:45 AM, with the assistance of administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 10/13/2024. During the visit the facility is at 76 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 6 may be bedridden and is cleared for 6 hospice waiver. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and are locked away under the kitchen. Bedrooms: There were eight (8) bedrooms designated for residents' use. Bedroom #1, bedroom #2, bedroom #3, bedroom #4, bedroom #5, and, bedroom #6 are for private used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #7 and bedroom #8 is for staff used and is located in the second floor. Continue to LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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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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 ASSISTED LIVING	FACILITY NUMBER: 197609036
	VISIT DATE: 02/06/2025

NARRATIVE

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Bathrooms: Bathrooms: There are eight (8) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 115.1 degrees Fahrenheit for bathroom #1 located inside bedroom #1. Bathroom #2 is inside bedroom #2. Hot water temperature was measured at 113.4 degrees Fahrenheit. Bathroom #3 is inside bedroom #3. Hot water temperature was measured at 115.1 degrees Fahrenheit. Bathroom #4 is inside bedroom #4. Hot water temperature was measured at 116 degrees Fahrenheit. Bathroom #5 is inside bedroom #5. Hot water temperature was measured at 117.1 degrees Fahrenheit. Bathroom #6 is inside bedroom #6. Hot water temperature was measured at 119.2 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Bathroom #7 and bathroom #8 is for staff, located beside the lock laundry room and in the second floor.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or bodies of water. The garage is attached and is used for storage.

Laundry service: There is enough linen available to change weekly or more if need. LPAs found cleaning supplies are being stored in a locked cabinet in the laundry area and is located beside the dining table.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is located on the 2nd floor. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Continue to LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVENING GRACE ASSISTED LIVING	FACILITY NUMBER: 197609036
	VISIT DATE: 02/06/2025

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Medications: are in a centrally stored and locked place in the kitchen, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: Planned activities are offered. LPA reviewed six (6) of the six (6) records and LPA found all files to be complete.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

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