565850425-5-16-2024-29-AS-KDUK-D5BQ76-20240516115437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850425
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:54:42 AM

Document Has Been Signed on 05/16/2024 11:54 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRACE LIVING 3		FACILITY NUMBER:	565850425
ADMINISTRATOR:	MICHAEL & IVY SUDJATI		FACILITY TYPE:	740
ADDRESS:	6 CARRIAGE SQUARE		TELEPHONE:	(805) 253-2112
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 0	DATE:	05/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Ivy Sudjati		TIME COMPLETED:	11:58 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kelly Dulek conducted an announced Pre-Licensing inspection at the facility today and met with Licensee Representative/Applicant Ivy Sudjati. Entrance interview conducted. The facility obtained a fire clearance on 11/03/2023 for 6 (six) bedridden, with a total capacity of 6 (six) residents. The Licensee Representative submitted a hospice waiver request and was approved for 6 (six) hospice residents. Component II was completed on 04/16/2024. During today's visit, LPA completed Component III with the Applicant Representative. The facility is a single-story home in the Oxnard area, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 09:58AM, the LPA, along with Applicant Representative, conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed: KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked box. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils. RESIDENT BEDROOMS/BATHROOMS: The resident bedrooms were observed. 2 (two) bedrooms are fully furnished for resident use. 1 (one) additional bedroom is currently furnished for staff use, but the Applicant indicated once licensed, this room will be utilized for residents only. The resident bathrooms were observed to be clean and sanitary with grab bars and non-skid mats. Hot water was measured in a common resident restroom and measured within the required range. The facility has a sufficient supply of linens and towels. Report continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GRACE LIVING 3	FACILITY NUMBER: 565850425
	VISIT DATE: 05/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

COMMON AREAS: The sitting area/activity room, family/television room, and dining area are furnished appropriately. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the entry way and common sitting area. Auditory devices on all exits were operational. Common areas were maintained at 72 degrees during the visit. Combination smoke alarms and carbon monoxide detectors were tested at 10:10AM and were operational at this time. Fire extinguishers were observed to be fully charged and Applicant stated they were recently purchased. LPA advised Applicant to maintain the receipt from purchase or proof of annual inspection. The facility has a laundry closet located in the office area, which contains an operational washing machine and dryer. Medications will be locked and centrally stored in a cabinet in the common sitting area. First aid supplies were reviewed and observed to be in compliance. Activity supplies were observed, including games and puzzles. LPA observed cameras in common areas. Licensee Representative indicated this is included in the facility's Plan of Operation as well as addressed in the facility Admission Agreement, as advised by the Centralized Application Bureau (CAB) Analyst.

OUTDOOR SPACE: The back yard area is enclosed. Both gates were observed to be self-closing and self-latching. The backyard contains a shaded seating area and appropriate outdoor furnishings, as well as outdoor activity supplies. Backyard contains a storage shed, which was observed to contain only non-hazardous items. There are no bodies of water on the premises. The backyard contains access to a locked garage. LPA observed the garage to contain extra cleaning supplies, storage and paper goods.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2