565850504-7-8-2025-29-AS-ECOZ-DJDTQA-20250708145536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850504
Report Date: 07/08/2025
Date Signed: 07/08/2025 02:56:15 PM

Document Has Been Signed on 07/08/2025 02:56 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:	GRACIE'S SENIOR CARE		FACILITY NUMBER:	565850504
ADMINISTRATOR/ DIRECTOR:	CASTILLO, GRACIELA		FACILITY TYPE:	740
ADDRESS:	1110 JANETWOOD DRIVE		TELEPHONE:	(805) 766-3427
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6		CENSUS: 4	DATE:	07/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Graciela Castillo		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 10:45 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Graciela Castillo and informed them of the reason for the visit. At 11:00 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 three (3) resident bedrooms, and two (2) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and purchased on 01/28/2025. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. Kitchen: The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives, sharps, and cleaning supplies were observed under the sink locked and inaccessible. Bedrooms: Each bedroom is equipped with clean mattresses, pillows, and bedding. There is a closet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. Bathrooms: The LPA observed both bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 11:07 a.m. water temperature in the common restroom was measured at 110.3 degrees Fahrenheit and at 114.8 degrees Fahrenheit in the residents room bathroom. Report will continue on LIC9099-C, 2nd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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: GRACIE'S SENIOR CARE	FACILITY NUMBER: 565850504
	VISIT DATE: 07/08/2025

NARRATIVE

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Common Areas: The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. Night-lights were present in the hallway and main bathroom. All doors have functioning auditory alarms when opened.

The garage: The garage is attached to the house and is locked. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored in a locked cabinet. There is a sufficient supply of emergency food and water.

Surrounding Grounds (Outdoors): The LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit.

Record Review: At 11:30 a.m. a review of facility files was initiated. The LPA reviewed four (4) out of four (4) resident files. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. The LPA reviewed five (5) out of five (5) Personnel files. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Facility records are stored in the locked closet in the living room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 07/01/2025). The LPA obtained Client Roster, Staff Roster and Insurance liability.

Medication Audit: At 2:00 p.m. the LPA conducted Medications audit for two (2) residents. The medications are locked in a locked closet in the living room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record

Interviews: The LPA conducted two (2) resident and one (1) staff Interviews. No immediate concerns were voiced.

No citations issued. Exit interview conducted. A copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC809 (FAS) - (06/04)

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