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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801919
Report Date: 11/14/2025
Date Signed: 11/14/2025 05:06:10 PM

Document Has Been Signed on 11/14/2025 05:06 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 LIVINGFACILITY NUMBER:
565801919
ADMINISTRATOR/
DIRECTOR:		IVY SUDJATIFACILITY TYPE:
740
ADDRESS:8 CARRIAGE SQUARETELEPHONE:
(805) 919-9589
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
11/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ivy SudjatiTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with House Manager Allan Santos and explained the reason for the visit. The LPA later met with Administrator Ivy Sudjati and explained the reason for the visit.

RECORDS: .A review of facility files was initiated. Facility records are stored in the locked cabinets and drawers. The LPA observed documentation of Infection Control Plan, Emergency Disaster Plan and last Disaster drill (conducted on 10/07/2025). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of five (5) resident files. Resident files reviewed were found to be complete. The LPA reviewed five (5) staff files. The following was observed: Two (2) staff (S1, S2) were missing one hour of restricted health conditions, hospice and postural support training.

MEDICATIONS: LPA reviewed medications for two (2) residents. The LPA observed the following: medications are centrally stored and locked in a locked cabinet in the laundry room area; medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record (CSMDR). However, during both resident's audit, the LPA observed eight or more medications without the strength documented on the CSMDR and each resident did not have one of their medications documented on the CSMDR.

The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Report will continue on LIC809-C, 2ND PAGE.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
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
FACILITY NUMBER: 565801919
VISIT DATE: 11/14/2025
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The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The facility has a supply of emergency food and water. The water temperature was measured at 105.3*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room, TV room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 3/27/2025. The carbon monoxide detector and smoke detectors were tested and were operational. Medications are centrally stored and in a locked cabinet in the laundry room. Cleaning supplies were observed to be locked in the laundry room and inaccessible to residents in care. The backyard has covered seating for resident use. Fireplace in the living room was covered with a screen.

BEDROOMS: There are six (6) resident bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.



RESTROOMS: The facility has two common restrooms for residents' use. There is half bathroom for guests and one restroom for staff. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the common hallway restroom near room #1 measured at 99.3*F which is under the temperature allowed of 105*F - 120*F.

INTERVIEWS: Interviews were conducted with one resident. No issues or concerns revealed.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2025 05:06 PM - It Cannot Be Edited


Created By: Esther Cortez On 11/14/2025 at 04:40 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
FACILITY NUMBER: 565801919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one restroom where the hot water measured 99.3 F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Administrator agrees to adjust the water temperature and submit a proof and a 5 day water temperature to log to LPA by the due date.
Type B
Section Cited
CCR
87465(h)(6)
87465(h)(6) Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:(A)The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C)The drug name, strength and quantity. (D)The date filled. (E) The prescription number and the name of the issuing pharmacy.(F) Instructions, if any, regarding control and custody of the medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as medications for two residents were not documented on the CSMDR and several medications were missing strength information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2025
Plan of Correction
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Administrator agrees to conduct a staff training on how to correctly document medications on the CSMDR, and will audit the CSMDR for all of the residents to ensure they are accurately filled. Will submit proof of training and letter confirming audit has been completed by due date.
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:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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