Grace Living

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Nov 14, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year inspection at the facility today. When the LPA arrived there were three staff and five residents present at the home. The LPA met with House Manager Allan Santos and explained the reason for the visit. Administrator Ivy Sudjati arrived approximately at 10:30 a.m. The LPA and House Manager 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 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 108.5*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 4/04/2024. At 9:45 a.m. 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 five (5) resident bedrooms and one (1) staff bedroom. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809-C. 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 #5 measured at 124.2*F which is over the temperature allowed of 105*F - 120*F. RECORDS: At 09:50 a.m. 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 10/07/2024). 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) out of twelve (12) staff files. The following was observed: Two (2) staff (S1, S2) were missing their annual required training. MEDICATIONS: Medications review began at 11:50 a.m. 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). During Resident #1's (R1's) audit, the LPA observed three (3) medications documented on the CSMDR with an incorrect prescription number. During R2's audit the LPA observed two (2) medications documented on the CSMDR with the incorrect prescription number. Administrator corrected all prescription numbers on the CSMDR for both residents during the visit. INTERVIEWS: Interviews were conducted with two (2) staff and attempted with two (2) residents. 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.the state’s words, verbatim · CDSS document, Nov 1, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with administrator Ivy Sudjati and explained the reason for the visit. The LPA 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 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 135.1*F which is over the temperature allowed of 105*F - 120*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 and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 4/19/2023. 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 lacked a screen. BEDROOMS: There are four resident bedrooms and two staff bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809-C. 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 measured at 140.2*F which is over the temperature allowed of 105*F - 120*F. MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the laundry room area. LPA reviewed medications and they appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. RECORDS: Resident files reviewed were found to be complete. Three staff files were reviewed and also found to be complete. Disaster drills are conducted quarterly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file. The updated liability insurance policy was provided to LPA during the visit. INTERVIEWS: Interviews were conducted with one staff and attempted 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.the state’s words, verbatim · CDSS document, Oct 25, 2023