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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850425
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:49:58 PM

Document Has Been Signed on 05/02/2025 04:49 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 3FACILITY NUMBER:
565850425
ADMINISTRATOR/
DIRECTOR:		MICHAEL & IVY SUDJATIFACILITY TYPE:
740
ADDRESS:6 CARRIAGE SQUARETELEPHONE:
(805) 253-2112
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 4DATE:
05/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Ivy SudjatiTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced annual inspection at the facility today and met with Administrator Ivy Sudjati. Entrance interview conducted.

At 10:45 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:
The facility is a single-story home, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and staff will remain awake at night.. The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 03/27/2025. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed the required postings in the entry way and common sitting area.

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items are stored in a locked box. Cleaning supplies and disinfectants are stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils.

RESIDENT 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 at 117 degrees Fahrenheit. Report will continue on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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 3
FACILITY NUMBER: 565850425
VISIT DATE: 05/02/2025
NARRATIVE
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COMMON AREAS: The sitting area/activity room, family/television room, and dining area are furnished appropriately.The facility has a laundry closet located in the office area, which contains an operational washing machine and dryer. LPA observed cameras in common areas.

OUTDOOR SPACE: The back yard area is enclosed. Both gates were observed to be self-closing and self-latching. The backyard contains a shaded seating area and appropriate outdoor furnishings, as well as outdoor activity supplies. Backyard contains a storage shed. There are no bodies of water on the premises. The backyard contains access to a locked garage. LPA observed the garage to contain extra cleaning supplies, storage and paper goods.

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 1/16/2025). Initial Staff Roster indicated there were fourteen (14) staff working for the facility, LPA verified fingerprinted clearance and association for the staff with LIS list and Guardian. The Guardian Portal revealed that Staff 1 (S1) was not associated to the facility. Administrator revealed that S1 no longer works at the facility and their last day was 04/26/25. The LPA reviewed five (5) out of five (5) resident files and five (5) out of twelve (10) staff files and the following was observed: Resident (R1) did not have a negative TB test on file, otherwise all records 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 centrally stored in a locked cabinet in the common sitting area.


During Resident #2 (R#2's) audit, the LPA observed one (1) medication not documented on the Centrally Stored Medication and Destruction Record (CSMDR) and four (4) medications documented incorrectly. During R3's audit. the LPA observed three (3) medications not documented on the CSMDR, and one medication documented incorrectly.

Interviews: The LPA attempted to conduct three (3) resident interviews. 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.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/02/2025 04:49 PM - It Cannot Be Edited


Created By: Esther Cortez On 05/02/2025 at 04:06 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 3
FACILITY NUMBER: 565850425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one (1) staff that was not associated to the facility and Administrator stated they worked at the facility for about a year which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2025
Plan of Correction
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Staff no longer works at the facility and last day was 04/26/25. Administrator will submit a self-certifiation letter they understand the regulation and will not have any staff at the facility that are not associated to the facility. Will submit letter by 5/3/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 04:49 PM - It Cannot Be Edited


Created By: Esther Cortez On 05/02/2025 at 04:06 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 3
FACILITY NUMBER: 565850425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 in one out of four residents that did not have a negative TB test results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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Administrator will submit residents negative TB test 05/16/25.
Type B
Section Cited
CCR
87465(h)(6)
87465 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:

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 in fout medications that were not documented and five medications were documented incorrectly which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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Administrator agrees to conduct a medication audit and enrsure all residents medications are documented correctly and will have all staff including the Administrator get medication training related to medication documentation by a third party vendor. Will submit proof by 05/16/2025.
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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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