565801919-5-19-2021-29-AS-KHEN-C3FW39-20210528165535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801919
Report Date: 05/19/2021
Date Signed: 05/19/2021 06:16:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210518132521

FACILITY NAME:	GRACE LIVING		FACILITY NUMBER:	565801919
ADMINISTRATOR:	IVY SUDJATI		FACILITY TYPE:	740
ADDRESS:	8 CARRIAGE SQUARE		TELEPHONE:	(805) 919-9589
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	05/19/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	IVY SUDJATI		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio and Zabel Chochian conducted an initial priority 1 investigation visit. At 12:40 PM, LPA's Angel Ascencio and Zabel Chochian toured facility with caregiver Allan Santos. At 1:10 PM, LPA's reviewed resident records. After reviewing resident records and staff interview, resident in question is not a current resident residing at this buidling. Therefore, the complaint allegations are deemed unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Administrator, and copy was provided via email.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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