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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850325
Report Date: 06/25/2025
Date Signed: 06/25/2025 03:40:32 PM

Document Has Been Signed on 06/25/2025 03:40 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 CAREFACILITY NUMBER:
565850325
ADMINISTRATOR/
DIRECTOR:		ALVIZURES, WALFRE A.FACILITY TYPE:
740
ADDRESS:4031 APRICOT RD.TELEPHONE:
(818) 335-2355
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 6DATE:
06/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Walfre AlvizuresTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Staff contacted the Administrator telephonically and informed them of the visit. The Administrator, Walfre Alvizures arrived at the facility at approximately 09:40am. Entrance interview conducted.

Starting at 09:45am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 09:45am. Knives and sharps were observed in a box locked under the kitchen sink. Cleaning supplies are kept locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 03/13/2025. Required postings were observed throughout the common space.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325
VISIT DATE: 06/25/2025
NARRATIVE
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Report Continued from LIC 809...

The LPA observed two (2) fireplaces adequately covered at the time of the visit. Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit. The LPA observed an adequate supply of emergency food and water. No obstructions or hazards observed inside or out.

LAUNDRY ROOM: The laundry room is next to the kitchen. Laundry detergents and toxins were observed locked and inaccessible at the time of the visit.

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Hand washing signs were observed posted at the time of the visit. The bathrooms were sufficiently stocked with supplies and paper towels. Personal hygiene items were also observed locked and inaccessible to residents in care. Starting at 09:54am, the hot water temperature was measured in bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the inspection.

BEDROOMS: There are five (5) bedrooms for resident use. One (1) bedroom is designated for double occupancy and four (4) bedrooms are designated for private / single occupancy. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff room on premises which was inaccessible to residents in care at the time of the inspection.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325
VISIT DATE: 06/25/2025
NARRATIVE
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Report Continued from LIC 809C...

OUTDOORS / SURROUNDING AREAS: The backyard was observed with two (2) sheds used for storage purposes inaccessible to residents at the time of the visit. There is one (1) side gate that self-latches. Property is fenced all around. The front yard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

RECORDS: The LPA reviewed Resident Records and Personnel Records starting at 10:15am.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, preplacement appraisals, consent for treatment form, and current needs and services plan. During record review, it was revealed that 3 out of 6 residents did not have a preplacement appraisal on file, 4 out of 6 residents did not have an appraisal and/or needs & service plan on file, and 5 out of 6 residents do not have a signed consent for treatment for on file. The Administrator stated they would complete the missing forms for all residents. Per record review of Resident #1's (R1's) physician's reports dated 03/05/2025, it indicates R1's ambulatory status as bedridden and facility does not have an approved fire clearance for bedridden. R1 was moved out of the facility during today's inspection.

Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. During record review, it was revealed that facility does not have a staff training binder; therefore, LPA was unable to verify yearly training for all staff. The Administrator stated they would work on completing all training for staff.

Report continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325
VISIT DATE: 06/25/2025
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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate.

MEDICATIONS: Medications review began at approximately 12:50pm. Medications are centrally stored in a locked cabinet by the kitchen. First Aid Kit and manual were observed and complete at time of the visit. Medications appeared to be given as prescribed at the time of the visit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). An immediate civil penalty in the amount of $500 for fire clearance violation is being assessed today. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 06/25/2025 03:40 PM - It Cannot Be Edited


Created By: Martha Arroyo On 06/25/2025 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as R1 is bedridden and facility does not have approved fire clearance for bedriiden, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee had R1 relocated during the inspection.

Civil Penalty assesed today for fire clearance violation.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 06/25/2025 03:40 PM - It Cannot Be Edited


Created By: Martha Arroyo On 06/25/2025 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

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 as there are no training records on file and LPA was unable to verify training hours for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The Licensee has agreed to have all staff training completed and send proof to CCL no later than POC due 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 as 3 out of 6 residents do not have a pre-admission appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The Licensee has agreed to complete pre-admission appraisals for all residents and send proof to CCL no later than POC due 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2025 03:40 PM - It Cannot Be Edited


Created By: Martha Arroyo On 06/25/2025 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WISDOM & GRACE SENIOR CARE
FACILITY NUMBER: 565850325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 as 4 out of 6 residents did not have an appraisal completed after being admitted to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The Licensee has agreed to complete an appraisal for all residents and send proof to CCL no later than POC due date.
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.

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 as 4 out of 6 residents do not have a needs & service plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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2
3
4
The Licensee has agreed to complete a needs & service plan for all residents and send proof to CCL no later than POC due 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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