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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609939
Report Date: 06/03/2022
Date Signed: 10/25/2023 12:44:17 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20210519135621
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: 4DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Ivy SudjatiTIME COMPLETED:
04:21 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff neglect led to Resident #1 (R1) sustaining pressure injuries
Staff neglected to seek timely medical attention for Resident #1 (R1)
INVESTIGATION FINDINGS:
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2
3
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5
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7
8
9
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13
Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver an amended report. LPA met with administrator Ivy Sudjati and explained the reason for the visit.

On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818.




(continued on 9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20210519135621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2022
NARRATIVE
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32
On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818.




(continued on 9099-C)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210519135621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2022
NARRATIVE
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3
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5
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7
8
9
10
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32
On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818.



(continued on 9099-C)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210519135621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
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On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818.



(continued on 9099-C)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210519135621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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On 6/3/2022, this report was issued in error under the incorrect complaint number. The report was re-issued on 6/8/2022 under the correct complaint number 29-AS-20200805152818.


Exit interview conducted and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210519135621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
000000000
1
2
3
4
5
6
7
None
1
2
3
4
5
6
7
None


8
9
10
11
12
13
14
None
8
9
10
11
12
13
14
None
Type B
06/10/2022
Section Cited
CCR
0000000000
1
2
3
4
5
6
7
None
1
2
3
4
5
6
7
None
8
9
10
11
12
13
14
None
8
9
10
11
12
13
14
None
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6