565801919-10-25-2023-29-AS-TCAA-CWXQYS-20231025123536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801919
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:36:40 PM

Document Has Been Signed on 10/25/2023 12:36 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 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:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ivy Sudjati		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with administrator Ivy Sudjati and explained the reason for the visit.

The LPA 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: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The facility has a supply of emergency food and water. The water temperature was measured at 135.1*F which is over the temperature allowed of 105*F - 120*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 4/19/2023. The carbon monoxide detector and smoke detectors were tested and were operational. Medications are centrally stored and in a locked cabinet in the laundry room. Cleaning supplies were observed to be locked in the laundry room and inaccessible to residents in care. The backyard has covered seating for resident use. Fireplace in the living room lacked a screen.

BEDROOMS: There are four resident bedrooms and two staff bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 10/25/2023 12:36 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE LIVING	FACILITY NUMBER: 565801919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(7)

Personal Accommodations and Services

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one fireplace which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Administrator will buy a fireplace screen and provide a photo of the screened fireplace to CCL on or before 11/1/2023.

Type B

Section Cited

CCR

87303(e)(2)

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of two water heater temperature readings which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Administrator will turn down the temperature on the water heaters (facility has two) and send temperature readings to CCL on or before 11/1/2023.

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	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE LIVING	FACILITY NUMBER: 565801919
	VISIT DATE: 10/25/2023

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RESTROOMS: The facility has two common restrooms for residents' use. There is half bathroom for guests and one restroom for staff. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the common hallway restroom measured at 140.2*F which is over the temperature allowed of 105*F - 120*F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the laundry room area. LPA reviewed medications and they appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record.

RECORDS: Resident files reviewed were found to be complete. Three staff files were reviewed and also found to be complete. Disaster drills are conducted quarterly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file. The updated liability insurance policy was provided to LPA during the visit.

INTERVIEWS: Interviews were conducted with one staff and attempted with one resident. No issues or concerns revealed.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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