405801845-8-20-2024-29-AS-EMIR-D8BTG4-20240820144232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801845
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:42:39 PM

Document Has Been Signed on 08/20/2024 02:42 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRACEFUL LIVING 2		FACILITY NUMBER:	405801845
ADMINISTRATOR:	JEFFIFER LAWRENCE		FACILITY TYPE:	740
ADDRESS:	389 SPANISH MOSS LANE		TELEPHONE:	(805) 489-3286
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 6	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:24 AM
MET WITH:	Jennifer Lawrence, Administrator		TIME COMPLETED:	03:00 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 (LPA) Miller arrived at 10:24 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator Jennifer Lawrence and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 shared bedrooms and 2 bathrooms. Facility currently occupies 6 residents and employs 5 full time staff, and one Administrator. LPA Miller was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and was working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and are locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and umbrellas are used for shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on 6/1/2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory 2 of which may be bedridden. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACEFUL LIVING 2	FACILITY NUMBER: 405801845
	VISIT DATE: 08/20/2024

NARRATIVE

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Staffing: The facility currently employes 5 full time staff, and one Administrator. Staff files were reviewed. Current Administrator Certificate expires 11/18/2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Staff have annual training completed for various subjects/topics and hours for 2023.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. LPA observed that food, snacks and drinks are available, when the residents want them. Cleaning solutions and equipment are stored separately from food supplies.

Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does currently has a resident receiving Home Health services. Exit door alarms are working.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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