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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850425
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:07:40 PM


Document Has Been Signed on 04/16/2024 02:07 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GRACE LIVING 3FACILITY NUMBER:
565850425
ADMINISTRATOR:MICHAEL & IVY SUDJATIFACILITY TYPE:
740
ADDRESS:6 CARRIAGE SQUARETELEPHONE:
(805) 253-2112
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 0DATE:
04/16/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael Sudjati, Administrator/Applicant
Ivy Sudjati, Administrator/ Applicant 		TIME COMPLETED:
01:50 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Michael Sudjati, Administrator/Applicant
Ivy Sudjati, Administrator/Applicant
Interview Method: Telephone interview

On April 16, 2024 at 1:00 PM, Applicants/Administrators participated in COMP II. Identification of the Applicants/Administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicants/Administrator. Report sent via email and informed return sign copy to CAB by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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