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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801347
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:43:19 PM

Document Has Been Signed on 04/04/2024 04:43 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:GRACE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
565801347
ADMINISTRATOR/
DIRECTOR:		LOUISA CERVANTESFACILITY TYPE:
735
ADDRESS:3005 LASSEN STREETTELEPHONE:
(805) 486-2832
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 5CENSUS: 5DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Louisa EspenaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 -Year inspection at the facility today. The LPA met with Administrator Louisa Cervantes at 09:47 AM 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:

Bedrooms: At 09:52 AM, the LPA began touring the client bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed stains on the walls of client rooms # two (2) and three (3).

Kitchen/Dining 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.

Common Areas: The living room was furnished appropriately. The carbon monoxide detector in the hallway and smoke alarms in each client room were tested and found to be operational. At 9:56 AM the LPA observed staff room #1 without a smoke detector. At 10:16 AM the LPA observed the den without a smoke detector. Upon observation, staff placed smoke detectors in staff room #1 and in the den. The fire extinguisher observed in the hallway was fully charged and last serviced on 06/07/2023. 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.

Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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 8
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: GRACE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 565801347
VISIT DATE: 04/04/2024
NARRATIVE
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Bathrooms: The facility has two common restrooms for resident use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. At 10:01 AM the hot water temperature was tested in the first common restroom, and it measured at 103.8 degrees F. At 10:32 AM the hot water temperature was tested in the second common restroom, and it measured at 101.4 degrees F.

Interviews: The LPA conducted two (2) client interviews, and two (2) staff interviews. No immediate concerns voiced at this time.

Record Review: At 11:45 a.m., a review of facility files was initiated. Facility records are stored in the locked cabinet in the dining room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 02/07/2024). The LPA obtained facility sketch, Client Roster, and Staff Roster. The LPA reviewed five (5) out of five (5) client files and the following was observed: Client #1 was missing admissions agreement. LPA observed four (4) out of four (4) staff files and the following was observed: Administrator certificate expired on 11/05/2023 and Administrator indicated the packet for renewal was sent late. Otherwise, all resident and staff files were in order.

Medications: A medication audit was initiated at 2:36 p.m. and the following was observed. LPA reviewed medications for two (2) clients. Medications are centrally stored and locked in a cabinet in the dining area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. During Client #2 (C2's) audit, the LPA observed noon medications Carbamazepine 200MG and Sodium Chloride 1GM not given. Upon observation, administrator stated C2 attends day program, due to the day programs restrictions, Physician has agreed noon medication can be given at 3:30 PM. Administrator called C2’s Physician for confirmation, however Physician was unavailable during the phone call. LPA observed noon medications given to C2 at approximately 3:46 PM.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):Civil penalty issued for the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and copy of the report and appeal rights provided to Administrator.

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

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 04/04/2024 04:43 PM - It Cannot Be Edited


Created By: Esther Cortez On 04/04/2024 at 03:24 PM
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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as staff room #1 and the den were observed without a smoke detector which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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 In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected. Staff placed a smoke alarm upon observation in both rooms. Plan of correction has been met.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/04/2024 04:43 PM - It Cannot Be Edited


Created By: Esther Cortez On 04/04/2024 at 03:24 PM
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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as both clients restroom water was measured below 105 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Hot water temperature was adjusted to attain correct temperatures during visit. Plan of correction was met during visit.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the adminastrtors certificate expired on 11/05/2023, the administrator indicated they submitted the renewal paperwork late, and they are not on the pending list on the CDSS website which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Administrator has agreed to dedvelop a plan how they are going to ensure to be in compliance and submit plan to CCL by due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/04/2024 04:43 PM - It Cannot Be Edited


Created By: Esther Cortez On 04/04/2024 at 04:08 PM
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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as medictions were not given to client according to the physicians directions, noon medications were given during the evening and evening were said to be given at bedtime which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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During todays visit Administrator contacted the physician to clarify the physician orders on when the medications can be given to the client. Administrator will develop a plan on how they will ensure clients are given their medication according to their physicians directions and submit plan to CCL by the end of day on due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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