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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801347
Report Date: 12/21/2021
Date Signed: 12/21/2021 05:15:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/21/2021 05:15 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: 3DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Julia EspenaTIME COMPLETED:
03:30 PM
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 Julia Espena at 11:30 AM. 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 11:40 AM the LPA began touring the dining and kitchen area. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and in the garage. At 11:41 AM, the LPA observed the medication cart stored in the dining area to be unlocked. At 11:45 AM, the LPA observed the knife drawer unlocked and cabinet under the sink with 409 cleaner, Windex and other cleaning supplies to be unlocked. Both were locked during the inspection.

Common Areas: The living room was furnished appropriately. The carbon monoxide detector and smoke alarms were tested and 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 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 11:54 AM the hot water temperature was tested in the first common restroom and it measured at 121.8 degrees F. The LPA also tested the water temperature with the licensee's thermometer and the water measured at 122 degrees F. The hot water heater was turned down during the inspection.

Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Smoke alarms were operational. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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Document Has Been Signed on 12/21/2021 05:15 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/21/2021 at 02:21 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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
8088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies (e)(1) Hot water temperature..... 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:
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The water heater was turned down during the inspection. The licensee shall submit proof of a five day water temperature log indicating the hot water is within the required range of 105-120 degrees F.

Proof shall be submitted to CCL by 12/28/2021
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Based on observation, the licensee failed to comply with the section cited above as the bathroom water temperature measured at 121.8 degrees F. which poses an immediate health and safety risk to residents in care.
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Type B
01/04/2022
Section Cited
CCR80075(f)

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80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
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The licensee shall submit proof all three staff have received first aid training to CCL by 01/04/2022.
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Based on record review, the licensee did not comply with the section cited above as three out of three staff files reviewed did not have current first aid/CPR card (expired 4/26/21) which poses a potential 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


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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: 12/21/2021
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Medication Review: At 12:14 PM, medications and medication records were reviewed for all three residents. Medications are centrally stored in a locked cabinet in the dining room area. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications were recorded on the centrally stored medication and destruction record. First aid supplies are sufficient.

Record Review: At 12:25 PM, the LPA began record review. Three resident files were reviewed and were found to be complete. P&I money and records were reviewed. Cash resources are kept separate and intact and are not co-mingled with facility funds. The licensee has a current surety bond.

Three staff files were reviewed. Three out of three staff do not have current first aid and CPR cards. The Administrator's administrator certificate expired on 10/13/2021. The Administrator stated she submitted the paper work for the renewal but it got returned as she was lacking some courses. The Administrator showed the LPA the letter regarding what she was lacking to renew her certificate. The Administrator stated she would be submitting the paperwork for the change of administrator to a family member who has current certificate.

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. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE), except for N95 masks as the facility only had two masks. The LPA will submit a request to the Woodland Hills North Regional Office on the facility's behalf to obtain more masks. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. 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: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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Document Has Been Signed on 12/21/2021 05:15 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/21/2021 at 02:13 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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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The items were secured during the inspection.

The licensee shall submit proof of an in-service training with staff regarding regulation 80075.

Proof shall be submitted to CCL by 12/28/2021.
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Based on observation, the licensee failed to comply with the section cited above as disinfectants, cleaning supplies, and knives were observed in unlocked drawers and cabinets which poses an immediate health and safety risk to residents in care.
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Type A
12/27/2021
Section Cited
CCR80075(k)(1)

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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:
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The medication cart was locked during the inspection. The licensee shall submit proof of an in-service training with staff regarding regulation 80075. Proof shall be submitted to CCL by 12/28/2021
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Based on observation, the licensee failed to comply with the section cited above as the medication cart was unlocked which poses 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2021 05:15 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/21/2021 at 02:37 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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2022
Section Cited
CCR
85064(b)

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85064 Administrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator.

This requirement is not met as evidenced by:
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The licensee shall submit documentation of the designation of a new administrator and the following documents: A letter from the licensee designating the new administrator and effective date, copy of the administrator certificate, LIC 501, LIC 508, LIC 308, Current 1st aid card, copy of photo ID, and LIC 500 with work schedule to CCL by 01/04/2022.
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Based on interview and observation, the licensee failed to comply with the section cited above as the facility currently does not have a certified administrator designated for the facility which poses a potential health, safety, and personal rights 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


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