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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801347
Report Date: 02/24/2025
Date Signed: 02/24/2025 12:27:58 PM

Substantiated


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
06/03/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240603091555
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:
02/24/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Louisa May NollanTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Client was lost while on an outing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortes conducted a subsequnet visit to investigate the allegation listed above. The LPA met with Licensee Julia Espena and explained the reason for the visit. Administrator Louisa May Nollan, arrived shortly thereater.

On 06/04/24, LPA Urena interviewed Licensee, Administrator and residents from approximately 11:03 a.m. to 12:20 p.m. During today's visit LPA Cortez conducted a file review and interview two (2) staff, and Client #1. Interviews revealed that on 05/30/24, C1 was lost during an outing around 2:30 p.m., and arrived to the facility on their own three and a half (3.5) hours later. File Review revealed that per C1's Physician Report, dated 07/13/20, C1 is not able to leave the facility unassisted. Based on the information gathered, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).Exit interview conducted, appeal rights discussed, and a copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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-20240603091555
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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The licensee will submit a plan describing how they will ensure the safety of all clients during outings. Submit plan to CCL by 2/25/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above as Licensee failed to supervise client during an outing resulting in client getting lost and returning to the facility on their own which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2