Grace Living 3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today. Upon arrival, the LPA was greeted by staff who then contacted the Administrator telephonically. The Administrator, Ivy Sudjati arrived during the inspection and the reason for the visit was explained. Entrance interview conducted. Beginning at 10:03 a.m., the LPA along with staff 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. The following was observed: Kitchen: The LPA inspected the kitchen/food service area at approximately 10:05 a.m. Knives and sharps were observed in a box locked under the kitchen sink. Cleaning supplies were observed locked and inaccessible under the kitchen sink at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The LPA observed an adequate amount of emergency food and water. At 10:08 a.m., the hot water temperature was measured in the kitchen sink at it measured at 115 degrees Fahrenheit. Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed several fire extinguishers to be fully charged with a charge date of 03/23/2026. Required postings were observed throughout the common space. There is a working telephone on premises. The LPA observed cameras in the common areas. First aid kit was observed to be complete. No hazards/obstructions observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... Restrooms: There are three (3) restroom for resident use. Bathroom was clean and sanitary and in operating condition with non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:12 a.m., the hot water temperature was measured in resident bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the visit. Personal hygiene items were observed locked at the time of the visit. Bedrooms: There are six (6) bedrooms for resident use. Bedrooms are designated as private / single bedrooms. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a cabinet by the hallway. Garage: The garage is attached to the facility. Detergents and cleaning supplies were observed locked and inaccessible to residents in care at the time of the visit. The LPA observed a sufficient amount of Personal Protection Equipment (PPE). Laundry Room: The washer and dryer were observed in a closet adjacent to the office. Outdoors: The backyard has a covered patio area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit. Records: Record review began at approximately 10:45 a.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order. Four (4) personnel files were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. Report Continued on LIC 809C... Report Continued from LIC 809C... Medications: Medication review began at approximately 12:05 p.m. Medications are centrally stored and kept in a locked cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be administered as prescribed at the time of the visit. Infection Control / Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 02/12/2026. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 12, 2026

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, May 2, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kelly Dulek conducted an announced Pre-Licensing inspection at the facility today and met with Licensee Representative/Applicant Ivy Sudjati. Entrance interview conducted. The facility obtained a fire clearance on 11/03/2023 for 6 (six) bedridden, with a total capacity of 6 (six) residents. The Licensee Representative submitted a hospice waiver request and was approved for 6 (six) hospice residents. Component II was completed on 04/16/2024. During today's visit, LPA completed Component III with the Applicant Representative. The facility is a single-story home in the Oxnard area, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 09:58AM, the LPA, along with Applicant Representative, conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed: KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked box. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils. RESIDENT BEDROOMS/BATHROOMS: The resident bedrooms were observed. 2 (two) bedrooms are fully furnished for resident use. 1 (one) additional bedroom is currently furnished for staff use, but the Applicant indicated once licensed, this room will be utilized for residents only. The resident bathrooms were observed to be clean and sanitary with grab bars and non-skid mats. Hot water was measured in a common resident restroom and measured within the required range. The facility has a sufficient supply of linens and towels. Report continued on LIC 809-C COMMON AREAS: The sitting area/activity room, family/television room, and dining area are furnished appropriately. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the entry way and common sitting area. Auditory devices on all exits were operational. Common areas were maintained at 72 degrees during the visit. Combination smoke alarms and carbon monoxide detectors were tested at 10:10AM and were operational at this time. Fire extinguishers were observed to be fully charged and Applicant stated they were recently purchased. LPA advised Applicant to maintain the receipt from purchase or proof of annual inspection. The facility has a laundry closet located in the office area, which contains an operational washing machine and dryer. Medications will be locked and centrally stored in a cabinet in the common sitting area. First aid supplies were reviewed and observed to be in compliance. Activity supplies were observed, including games and puzzles. LPA observed cameras in common areas. Licensee Representative indicated this is included in the facility's Plan of Operation as well as addressed in the facility Admission Agreement, as advised by the Centralized Application Bureau (CAB) Analyst. 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, which was observed to contain only non-hazardous items. 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. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Michael Sudjati, Administrator/Applicant Ivy Sudjati, Administrator/Applicant Interview Method: Telephone interview On April 16, 2024 at 1:00 PM, Applicants/Administrators participated in COMP II. Identification of the Applicants/Administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicants/Administrator. Report sent via email and informed return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Apr 16, 2024