567609939-4-2-2025-29-AS-ECOZ-DFCUGL-20250402153430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609939
Report Date: 04/02/2025
Date Signed: 04/02/2025 03:37:31 PM

Document Has Been Signed on 04/02/2025 03:37 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/ DIRECTOR:	SUDJATI, IVY		FACILITY TYPE:	740
ADDRESS:	46 CARRIAGE SQUARE		TELEPHONE:	(310) 562-8250
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Ivy Sudjati		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 10:00 a.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 shortly thereafter. At 10:15 a.m. the LPA conducted a tour of the physical plant with the Administrator 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, and three (3) restrooms (2 private and 1 communal). The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 03/27/2025. At 10:44 a.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. 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. Bedrooms: All 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. The hot water temperature in resident restrooms measured between 106.5 and 111.9 degrees Fahrenheit. Report will continue on LIC809-C.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Esther Cortez	TELEPHONE: (747) 230-2225
	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/02/2025

NARRATIVE

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Common Areas: These included the living room and dining areas. 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.

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 11:00 a.m. a review of facility files was initiated. The LPA obtained documentation of Resident and Staff Rosters, Infection Control, Disaster prevention and last fire drill (conducted on 1/10/2025). The LPA reviewed five (5) out of five (5) resident files and five (5) out of twelve (12) staff files. All files were complete and current..

Medications: At 1:00 p.m., a medications review was initiated for two out of five residents and the following was observed. The medications were stored in a locked cabinet in the laundry room and inaccessible to the residents. Medications were documented on the Facility Centrally Stored Medication and Destruction Record (CSMDR). During Resident #1 (R#1's) audit, the LPA observed a list of medications for R1, however several medications were not present. Upon observation, the administrator stated that the hospice agency has not sent them as they will be discontinued. During R2's audit. the LPA observed three (3) medications with the incorrect quantity of medications left based on the start dates and quantities on the CSMDR and the Medication Administration Record (MAR). In addition R1 has gone 2 to 3 days without one of their medications due to it not being refilled on time.
Interviews: The LPA conducted two (2) staff and two (2) resident Interviews, attempted to conduct a third resident interview however the resident was sleepy. No immediate concerns were voiced.

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 the Administrator.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/02/2025 03:37 PM - It Cannot Be Edited

Created By: Esther Cortez On 04/02/2025 at 03:10 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GRACE LIVING 2	FACILITY NUMBER: 567609939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one of five residents as they did not have one of their medications for 2 to 3 days due to not being refilled, and 3 of their other medications had discrepencies in the medication count they have more tablets than should have based on the start dates and qunatities documented on the CSMDR and MAR which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator agrees to develop a written procedure/plan for staff to ensure refills are obtained timely and conduct medication staff training. Submit plan and proof of training by 04/08/2025.

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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 596-4343

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (747) 230-2225

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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