197608993-5-3-2023-31-AS-APAA-CRGSV2-20230503141202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608993
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:13:12 PM

Document Has Been Signed on 05/03/2023 02:13 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: 6	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gladys Maniago, Administrator		TIME COMPLETED:	02:40 PM

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At 12:00pm Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the staff, Sinagtala Limbo, who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit.

At 12:10pm, LPA conducted a tour of the facility and the following was observed:

Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 12:15pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen and it was last serviced on 12/20/2022.

Medications: At approximately, 12:20pm LPA observed medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care. LPA also observed a First Aid Kit complete with the required items as per Title 22 Regulations.

Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIVING GRACEFUL RCFE	FACILITY NUMBER: 197608993
	VISIT DATE: 05/03/2023

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tested and observed to be operational. Staff bedroom is located by the kitchen.

Bathrooms: At 12:30pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 109.3°F. LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 12:45pm LPA toured the outside area of the facility. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents.

The garage: Laundry area is located by the attached garage and kept locked and inaccessible to residents.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:00pm they were tested and observed to be operational.

Between 1:05pm to 2:00pm, LPA reviewed records of three (3) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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