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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609939
Report Date: 02/22/2023
Date Signed: 02/22/2023 04:28:13 PM


Document Has Been Signed on 02/22/2023 04:28 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:GRACE LIVING 2FACILITY NUMBER:
567609939
ADMINISTRATOR:SUDJATI, IVYFACILITY TYPE:
740
ADDRESS:46 CARRIAGE SQUARETELEPHONE:
(310) 562-8250
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ivy SudjatiTIME COMPLETED:
03:08 PM
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Licensing Program Analysts (LPA) Teresa Camara arrived at the facility unannounced to conduct a required
annual visit at 1:20 PM. This annual had a specific emphasis on infection control practices and procedures.
The LPA met with Administrator Ivy Sudjati and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. 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 mats. The LPA observed sufficient amounts of soap and paper products in each restroom. 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. The LPA observed the required postings. Fire extinguishers was last serviced 4/6/22. The smoke detectors and carbon monoxide were tested and functioned properly during the visit. The backyard had furniture appropriate for residents' use. Laundry room had locked storage area for supplies. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medication, knives and cleaning supplies were in locked cabinets. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. 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 they are 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. No citations were issued during today's visit. Exit interview conducted. Copy of the report provided to administrator via email.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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