<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801347
Report Date: 04/15/2022
Date Signed: 04/15/2022 04:26:58 PM

Document Has Been Signed on 04/15/2022 04:26 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRACE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
565801347
ADMINISTRATOR:JULIA ESPENAFACILITY TYPE:
735
ADDRESS:3005 LASSEN STREETTELEPHONE:
(805) 486-2832
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 5CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Julia Espena and Louisa CervantesTIME COMPLETED:
11:10 AM
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) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Licensee Julia Espena and Administrator Louisa Cervantes. The home is vendored by Tri-Counties Regional Center as a level 3 home.

Beginning at 9:43 AM, the LPA, along with the licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This Required - 1 Year inspection has a specific emphasis on infection control practices and procedures.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies and items that could pose a danger were secured and in locked cabinet. Medications and facility records are stored in a locked cabinet in the dining room area.

Common Areas: The living room was furnished appropriately. The carbon monoxide detector and smoke alarms in the common areas and bedrooms were tested at 9:55 AM and were found to be operational. The two fire extinguishers were fully charged and last serviced on 07/23/2021. Infection control signs are posted through out the facility. The facility has two common restrooms for resident use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. At 9:50 AM the hot water temperature was tested in the second common restroom and it measured at 105.8 degrees F. The backyard has covered seating for resident use.

Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 565801347
VISIT DATE: 04/15/2022
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
26
27
28
29
30
31
32
Infection Control: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. Infection control signs are posted in the restrooms and through out the facility. The LPA observed an adequate supply of Personal Protective Equipment (PPE) stored in the garage. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited during today's inspection. The LPA did request the Licensee to submit an updated facility sketch. Exit interview and report reviewed with the Licensee. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2