565801919-10-26-2022-29-AS-DCOZ-CKKVJ4-20221026162807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801919
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:29:15 PM

Document Has Been Signed on 10/26/2022 04:29 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Allan Santos, House Manager		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Cortez conducted an on-site 1-year infection control annual visit to the facility above on 10/26/2022 around 3:00 PM. LPA met with House Manager and explained the purpose of the visit.

LPA then took a physical plant tour of the facility with House Manager. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted or any residents are showing any signs, symptoms, or a temperature. Signs are posted on entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, residents, and visitors are informed of the facilities infection control policies. New residents and staff will be tested, and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

The Administrator and House Manager are in charge of infection control and provides training and education to staff, residents and visitors.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Diego Cortez	TELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE LIVING	FACILITY NUMBER: 565801919
	VISIT DATE: 10/26/2022

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Staff will use full PPE with N95 masks and face shields when around with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility contains 6 single rooms. Restrooms are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission, and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents’ medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and Resident records are kept in a locked cabinet. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. Fire extinguishers were charged and inspected annually. Smoke alarms and carbon monoxide alarms were in good working order.

At approximately 3:40 PM, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there is 1 staff member currently working in the facility and has not been associated to the facility prior to their employment.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D),

Exit interview conducted. Report, Civil penalties and Appeal Rights issued via email to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Diego Cortez	TELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2022 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GRACE LIVING	FACILITY NUMBER: 565801919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above as one (1) facility staff was not associated to work in the facility prior to working in the facility which poses an immediate health and safety risk to residents in care
	POC Due Date: 10/26/2022
	Plan of Correction
1 2 3 4	Administrator immediately associated staff. POC was cleared during the visit. Civil Penalty assessed in the amount of $500.

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Diego Cortez	TELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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