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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801347
Report Date: 06/04/2024
Date Signed: 06/04/2024 06:58:30 PM

Document Has Been Signed on 06/04/2024 06:58 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: 4DATE:
06/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:24 PM
MET WITH:Julia EspenaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management Deficiencies visit. The visit was conducted in collaboration with the Tri-Counties Regional Center staff, Patrick Brown, Quality Assurance Specialist and Liz Aced-Arnett, Quality Assurance Specialist. The LPA met with Licensee Julia Espena, and Louisa May Nollan, and explained the reason for the visit.

During an investigation under complaint control # 29-AS-20240603091555, interviews revealed that the facility administrator and licensee failed to report to the Department an incident that took place on May 30, 2024, in which Resident #1 (R1) got lost during an outing. The R1 arrived at the facility on their own, later the same day. The R1 stated that they took public transportation to get to the facility. When asked what happened after using the restroom, the R1 stated that when they came out of the restroom, they did not see the facility staff and thought that they left without them. R1 decided to get back to the facility by taking public transportation. The licensee and administrator stated they were having internet issues and were not able to send the report.


The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

Deficiencies were cited. Exit interview was conducted. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 06/04/2024 06:58 PM - It Cannot Be Edited


Created By: Sandra Urena On 06/04/2024 at 12:25 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: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
80061

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80061-Reporting requirementsEach licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to,those specified in this section.(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1)below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.This requirement is not met as evidenced by:
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POC: Licencee has agreed to review the regulations pertaining to reporting requirements and will send self certification by June 7th, 2024 to the department.
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Based on the information obtained through interviews, and data search, the licensee failed to call and submit a written Incident report to the department, which poses a potential health and safety risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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