565801347-2-24-2023-29-AS-KLOZ-CPCQE6-20230224110548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801347
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:47:07 PM

Document Has Been Signed on 02/24/2023 02:47 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 FACILITY		FACILITY NUMBER:	565801347
ADMINISTRATOR:	LOUISA CERVANTES		FACILITY TYPE:	735
ADDRESS:	3005 LASSEN STREET		TELEPHONE:	(805) 486-2832
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 5		CENSUS: 3	DATE:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Louisa Cervantes		TIME COMPLETED:	11:10 AM

NARRATIVE

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 -Year inspection at the facility today. The LPA met with Administrator Louisa Cervantes at 10:00AM and explained the reason for the inspection. The home is vendored by Tri-Counties Regional Center as a level 3 home.

The LPA, along with facility Administrator, 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. The following was observed:

Kitchen/Dining area: At 10:08 AM, the LPA began touring the dining and kitchen area. Kitchen appliances appeared to be in operable condition. Knives are stored in a locked drawer. Cleaning supplies are in a locked cabinet underneath the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and in the garage. During the inspection, the LPA observed the medication cart stored in the dining area to be unlocked with the key in the lock. The Administrator locked the cart and removed the key during the inspection.

Common Areas: The living room was furnished appropriately. The carbon monoxide detector in the hallway and smoke alarms in each room were tested at 10:15 AM and found to be operational. The fire extinguisher observed in the hallway was fully charged and last serviced on 06/06/2022. Infection control signs are posted through out the facility. The backyard has a covered area for resident use. The washing machine and dryer are located outside. There is a locked cabinet for detergent and cleaning supplies. The facility has two common restrooms for resident use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. At 10:21 AM the hot water temperature was tested in the first common restroom and it measured at 105.8 degrees F.

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: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 565801347
	VISIT DATE: 02/24/2023

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Infection Control: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if needed. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 6. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2023 02:47 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 02/24/2023 at 10:46 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 565801347
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(1)

80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the medication cart was unlocked with the key in the lock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2023
	Plan of Correction
1 2 3 4	The Administrator locked the cart and removed the key during the inspection. Plan of correction is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Desaree Perera

LICENSING EVALUATOR NAME:

Kasandra Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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