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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801347
Report Date: 12/26/2023
Date Signed: 12/26/2023 11:31:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2023 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20230314153949
FACILITY NAME:GRACE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
565801347
ADMINISTRATOR:LOUISA CERVANTESFACILITY TYPE:
735
ADDRESS:3005 LASSEN STREETTELEPHONE:
(805) 486-2832
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:5CENSUS: 4DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Louisa Mae Cervantes-AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff is not qualified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint inspection at the facility today to deliver findings regarding the above allegation. The LPA met with staff and explained the reason for the inspection. Administrator Louisa Mae Cervantes arrived shortly

On 03/14/2023, the Department received a complaint alleging Staff #1 (S1) physically abused Client #1 (C1) by pushing C1 resulting in a fractured hip, Facility staff hit C1, and S1 is not qualified. On 03/15/2023, LPA KaSandra Lopez conducted the initial complaint inspection visit. During the inspection, LPA Lopez began record review at 9:55 AM and conducted an interview with S1 at 10:00 AM. LPA Lopez also conducted interviews with the Administrator Louisa Mae Cervantes and Licensee Julia Espena during the inspection. Copies of pertinent records were also obtained. Community Care Licensing Investigations Branch Investigator Christine Ferris was assigned to investigate the allegations of S1 physically abused C1 by pushing C1 resulting in a fractured hip and Facility staff hit C1. Report will continue on LIC909-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20230314153949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GRACE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 565801347
VISIT DATE: 12/26/2023
NARRATIVE
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On 06/21/2023 a subsequent inspection was conducted. During this visit, LPA Lopez delivered unsubstantiated findings for allegations Staff #1 (S1) physically abused Client #1 (C1) by pushing C1 resulting in a fractured hip and Facility staff hit Client #1 (C1). Further investigation was needed for the allegation of Staff is not qualified.

The remaining allegation of Staff is not qualified alleges S1 is not qualified to be a caregiver. Record review revealed S1 has current first aid training, passed year one and year two of Direct Support Professional (DSP) training, and has current required annual training. S1 also has TB clearance and physical signed by a physician clearing S1 to work as a caregiver. The interview with S1 revealed they are also able to communicate with staff and clients at the home. Based on the information obtained, there is insufficient evidence to substantiate S1 is not qualified. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2