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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850504
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:03:51 AM


Document Has Been Signed on 06/19/2024 10:03 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GRACIE'S SENIOR CAREFACILITY NUMBER:
565850504
ADMINISTRATOR:CASTILLO, GRACIELAFACILITY TYPE:
740
ADDRESS:1110 JANETWOOD DRIVETELEPHONE:
(805) 766-3427
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Graciela Castillo (Administrator/Licensee)TIME COMPLETED:
08:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census : 4
Method: Telephone call with CAB
COMP II Participants: Graciela Castillo (Administrator/Licensee) & Tammy Edwards (Analyst).

Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Administrator/Licensee'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
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) -65-7817
LICENSING EVALUATOR NAME: Tammy EdwardsTELEPHONE: 916-651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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