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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850504
Report Date: 07/08/2024
Date Signed: 07/08/2024 01:02:56 PM


Document Has Been Signed on 07/08/2024 01:02 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
07/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Graciela CastilloTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs), Martha Arroyo, Trevor Byrne, and Angela Barutyan conducted a pre-licensing visit to this property at 10:00 a.m. LPAs met with Applicant Representative Graciela and Cheryl Macht as this is a change of ownership application from Grandma Ebing’s Senior Care #567609752 to Gracie’s Senior Care #565850504. The applicant has obtained fire clearance for a total capacity of six (6) residents, five (5) non-ambulatory in bedrooms #1 - #3, and one (1) bedridden in bedroom #3. The facility has a dementia program in place.

LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 10:24 a.m., hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPAs observed one (1) fire extinguisher to be new and fully charged on 01/27/2024.

There are three (3) double occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is a closet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms, and they measured between 105- and 120-degrees Fahrenheit. LPAs observed trash cans with tight fitting lids at the time of the visit.

LPAs toured the kitchen area at 10:13 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives, sharps, and cleaning supplies were observed under the sink locked and inaccessible. The kitchen has a sufficient supply of plates, cups, cookware and utensils.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
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: GRACIE'S SENIOR CARE
FACILITY NUMBER: 565850504
VISIT DATE: 07/08/2024
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(Report Continued from 809...)

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. Night-lights were present in the hallway and main bathroom. All doors have functioning auditory alarms when opened.

Medications are stored and locked in the main entrance hallway closet. Facility records and First aid kit was observed in the main closet. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

The garage is attached to the house and is inaccessible. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored in a locked cabinet. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPAs observed the backyard, which has a covered outdoor area with a table and chairs for resident use.

Physical plant is consistent with the submitted facility sketch / floor plan.

Comp III conducted with Applicant Representative.

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. The report was reviewed, and a copy was provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC809 (FAS) - (06/04)
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