425850746-7-23-2026-29-AS-MRAN-DW9R7G-20260723124618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850746
Report Date: 07/23/2026
Date Signed: 07/23/2026 12:46:32 PM

Document Has Been Signed on 07/23/2026 12:46 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:	GRAPEVINE RCFE, THE		FACILITY NUMBER:	425850746
ADMINISTRATOR/ DIRECTOR:	DUARTE, AUDIFAS		FACILITY TYPE:	740
ADDRESS:	1130 GRAPEVINE RD		TELEPHONE:	(805) 689-7161
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 0	DATE:	07/23/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:08 AM
MET WITH:	Audifas Duarte		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Melisa Rankin conducted a Pre-licensing visit and met with the Applicant Audifas Duarte.

This is a new facility application for a Residential Facility for the Elderly (RCFE) for six (6) non-ambulatory residents; two (2) of which may be bedridden. Fire Clearance was approved on 04/08/2026. Bedridden rooms were approved in the 2 bedrooms adjacent to the dining room and kitchen area.

LPA and the applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility will be following Title 22 Regulations.

There is a functioning telephone on the premises. The emergency exiting plans/sketches are posted at the entrance. The emergency telephone numbers are posted on the bulletin board near the front entry way and in the dining room.

COMMON AREAS: The living room area is equipped with a television and comfortable furniture. There is a dedicated area for the posting of required documents. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. A fire extinguisher is located near the kitchen, extinguisher was charged and inspected on 4/3/26.

BEDROOMS: The facility has six (6) resident bedrooms, all bedrooms have direct exits to the outside. There are fire sprinklers in the facility. There are fire doors leading into the bedridden rooms. All residents’ rooms are set up with beds, nightstands, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. In addition, no bedroom is used as a passageway to another room. There is a office located next to the living room. All rooms were free of odors. All window screens were clean and maintained in good repair. Continued 809-C

Kelly Burley
Melisa Rankin
	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

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

FACILITY NAME: GRAPEVINE RCFE, THE	FACILITY NUMBER: 425850746
	VISIT DATE: 07/23/2026

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KITCHEN: Kitchen knives are locked and inaccessible in a locked kitchen cabinet. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean, and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 118.5 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area.

BATHROOMS: There are four (4) bathrooms. Two (2) restroom are in a resident bedroom, the other two (2) are located down the 2 hallways. All bathrooms are equipped with toilets and shower grab-bars, and slip resistant flooring or mats. Hot water delivered was between 116 and 118.6 degrees Fahrenheit.

LAUNDRY: There is a laundry area equipped with washer and dryer. The washer and dryer are in the garage. Detergents and cleaning supplies will be stored in the garage.

SURROUNDING GROUNDS/OUTDOOR AREA: The exterior passageways were clean. The patio is furnished with outdoor furniture for residents’ use. The building has a central entrance for residents and visitors. Side passageways are cleared and have self-latching gates. There is no body of water observed at this time.

RECORDS: Administrator/Licensee has a administrator certificate that expires 7/21/2027. Record keeping, training records and requirements were discussed. The residents’ and staff files will be stored in the office location and kept confidential.

MEDICATIONS: Medications will be stored in a locked cabinet in the office. Medication records and requirements, including PRN were discussed. First Aid Supplies were reviewed and complete.

Component III was conducted in conjunction with the visit.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC809 (FAS) - (06/04)

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