567609939-3-30-2022-29-AS-AASO-CCZPFC-20220330111630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609939
Report Date: 03/28/2022
Date Signed: 03/30/2022 11:17:08 AM

Document Has Been Signed on 03/30/2022 11:17 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 2		FACILITY NUMBER:	567609939
ADMINISTRATOR:	SUDJATI, IVY		FACILITY TYPE:	740
ADDRESS:	46 CARRIAGE SQUARE		TELEPHONE:	(310) 562-8250
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 5	DATE:	03/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Ivy Sudjati		TIME COMPLETED:	03:30 PM

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 Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 2:20 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Ivy Sudjati and Allan Santos and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside at 2:40 p.m. to ensure there are no health and safety hazards. Entrance interview conducted. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 total bedrooms – two (2) bedrooms are shared rooms, two (2) bedrooms are private rooms and one (1) room is for staff. RESTROOMS: Three (3) restrooms for resident use were observed to be clean and sanitary and in operating condition. The bathrooms and showers were also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Water temperature was tested and was within normal ranges. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit. The backyard has a covered area equipped with furniture for resident use. There are no bodies of water noted. Laundry room contained locked storage area for laundry supplies. Medication was observed to be locked and contained at least a 30-day supply. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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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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 2	FACILITY NUMBER: 567609939
	VISIT DATE: 03/28/2022

NARRATIVE

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable
and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning
supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s
infection control practices at 3:10 p.m. There is one (1) entry into the facility. Upon entry, the facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor
visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and is able to obtain more if needed The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
- More COVID -19 Posters throughout the facility

No citations were issued today's visit. Exit interview conducted. Copy of the report provided to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

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