197608993-6-21-2022-31-AS-JMAZ-CFLR28-20220621123756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608993
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:38:47 PM

Document Has Been Signed on 06/21/2022 12:38 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LIVING GRACEFUL RCFE		FACILITY NUMBER:	197608993
ADMINISTRATOR:	GLADYS MANIAGO		FACILITY TYPE:	740
ADDRESS:	10651 DESPLAIN PLACE		TELEPHONE:	(818) 468-7200
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 5	DATE:	06/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Gladys Maniago		TIME COMPLETED:	12:45 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

On 06/21/22 at 11:35 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Gladys Maniago. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 11:40 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff took LPA’s temperature upon arrival. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medications are centrally stored in a locked cabinet in the kitchen area. Garage: There is door next to the kitchen that leads into the garage. The garage is used for additional storage and laundry area. The chemicals in the garage are stored in a locked cabinet. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:55 a.m. and appear to be functional. Fire extinguisher has a purchase date of 12/01/2021. Common Areas: All common areas were observed to be clean and properly furnished. Resident Rooms: Facility has six (6) bedrooms which of five (5) are designated for resident use. Facility has two live-in staff. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture.

Continue on 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIVING GRACEFUL RCFE	FACILITY NUMBER: 197608993
	VISIT DATE: 06/21/2022

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
26
27
28
29
30
31
32

Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured within regulation. All trash cans located in the bathrooms had tight fitting lids. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water.

Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2