567609939-4-25-2024-29-AS-ECOZ-D4NW3K-20240425165603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609939
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:56:40 PM

Document Has Been Signed on 04/25/2024 04:56 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
WOODLAND HILLS N.ASC, 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: 4	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Ivy Sudjati		TIME COMPLETED:	05:00 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	At 02:20 p.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Ivy Sudjati arrived approximately around 4:15 p.m. At 2:39 p.m. the LPA conducted a tour of the physical plant with House Manager Alan Santos to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms (one currently vacant), and three (3) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 04/04/2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. LPA informed administrator that their annual licensing fee is not current. Administrator stated they will be paying the licensing fee today. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. At 2:41 p.m. the LPA observed an unlocked box that stores the kitchen knives on the counter top to the left of the stove. Upon observation, staff stated the box had been left unlocked for an hour and locked the box. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 03:43 p.m. water temperature in resident’s restroom in room #2 was measured at 108.1 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE LIVING 2	FACILITY NUMBER: 567609939
	VISIT DATE: 04/25/2024

NARRATIVE

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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the TV room, which is covered with furniture and the TV. There were no obstructions and/or tripping hazards throughout the facility.

The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no open bodies of water on the premises.

Record Review: At 03:46 p.m. a review of facility files was initiated. The LPA reviewed two (2) out of four (4) resident files. The following was observed: Two residents (R1, R2) did not have a pre-placement appraisal (LIC 603), appraisal/needs and services plan (LIC625), and additional required documents. Upon observation, administrator Ivy Sudjati stated they use an online program for their file system and had not printed the residents files to their folder, and will print all required documents.

Interviews: The LPA conducted two (2) resident Interviews. No immediate concerns were voiced.

Due to time constraints the LPA will return at a later date to complete annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Ivy Sudjati.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2024 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACE LIVING 2	FACILITY NUMBER: 567609939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

8775(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above in as an unlocked box of kitchen knives was accessible to residents in care for an hour which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Staff locked the box of kitchen knives. Plan of correction has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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