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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602863
Report Date: 10/02/2024
Date Signed: 10/02/2024 09:58:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230404133757
FACILITY NAME:HOUSE OF GRACE 2FACILITY NUMBER:
198602863
ADMINISTRATOR:AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:2815 MESA DRIVETELEPHONE:
(626) 716-1033
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Edna Arbis - CaregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff did not provide proper supervision to resident in care.
Neglect/lack of care & supervision led to resident sustaining a fracture.
Staff did not seek timely medical care for resident in care.
Staff did not provide a copy of the signed admission agreement to resident's representative in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Edna Arbis (Caregiver) and explained the reason for the visit.

The investigation consisted of the following: On 04/05/2023, the Investigation Bureau (IB) accepted the complaint for investigation and assigned it to Investigator Douglass Real. On 04/06/2023, LPA Joe Katrdzhyan reviewed the file of Resident #1 (R1) and obtained copies of the following documents: Identification and Emergency Information Sheet, Admission Agreement, Agreements and Consent for Medical Treatment, Physician's Report, Resident Appraisal, Durable Power of Attorney, Unusual Incident/Injury Report, Centrally Stored Medication and Destruction Record, PRN Authorization Letter, Radiology Report, Facility Daily Logs/Notes, Transportation Invoice, Client Personal Property and Valuables, Resident Roster, Staff Roster. On On 09/03/2024, LPA Mora interviewed Administrator, Staff 1 (S1) and Staff 2 (S2) to gather additional information regarding the above allegations. During today's visit, LPA interviewed the second Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 (R1) representative, and Resident 2 - Resident 7 (R2 - R7).(Continued to LIC 9099)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20230404133757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
VISIT DATE: 10/02/2024
NARRATIVE
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IB investigation and documents obtained revealed the following: Resident 1 (R1) was admitted to the facility on February 22, 2023. R1 physician report noted that R1 was non-ambulatory and suffered from dementia. The resident appraisal noted that resident was ambulatory (contradicted physician report), does not use a walker or wheelchair, but needs help with transfers and bathing, and was a fall risk. On February 28, 2023, at about 3 am, Staff 1 (S1) heard noises and saw R1 standing in the hallway and was taken back to bed. At around 6:30-7am, Staff 2 (S2) saw R1 on the floor near the bed. R1 could not get up on his/her own and needed assistance from staff. According to S1, the resident made a noise indicating being in pain. S1 asked R1 if it hurt and R1 pointed to the hip. Around 9am, the administrator contacted R1's POA to advise them of the incident and asked them to come and take the resident for an x-ray. The POA husband came to the facility about noon but was turned away by the staff because the resident was sleeping. Staff advised that they would contact the POA if the resident's status changed. The administrator texted the POA about 12:30pm and advised that the resident was still in pain. At 2:30pm, paramedics were called but they would not transport resident as they deemed it to be a non-emergency. On March 1, 2023 at 8:43am, the administrator texted the POA to get the resident an x-ray. The husband of the POA picked up the resident around 12pm and took him to urgent care for an x-ray. The resident returned to the facility pending the results. The following day March 2, 2023, they were notified that the resident suffered a fracture. The paramedics were called and refused to transport the resident as it was not an emergency. The administrator finally arranged for private transportation to the hospital. The resident went to the hospital and did not return to the facility.

On 09/03/2024, LPA Mora conducted a subsequent visit to gather additional information and obtained the following per interviews with Administrator, S1 and S2: there was no care plan for this resident and Administrator stated because there is no Title 22 regulation that says they have to have a care plan because they are not a medical facility. Administrator also stated that staff check up on the residents while they are awake and once the residents go to sleep the staff do not conduct additional checkup because this is not a 24-hour care and supervision facility. There are no staff awake and they are just there for emergencies. S1 and S2 both confirmed that they sleep at night. S1 sleeps in the caregiver room and S2 sleeps in the living room. S1 showed LPA that they have audio baby monitor in each of resident bedrooms, and they place one in the living room for S2 and one in the staff bedroom for S1. If they hear anything on the monitors, then they wake up to go assist the residents. Both S1 and S2 confirmed that they were asleep on February 28, 2023.
(Continued to LIC 9099-C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20230404133757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
VISIT DATE: 10/02/2024
NARRATIVE
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Regarding allegation "Staff did not provide a copy of the signed admission agreement to resident's representative in a timely manner" it is alleged that R1's representative requested for a copy of the admission agreement on the day of admission and administrator did not provide it in a timely manner. R1's representative stated that the other attempts to get a copy was done via text on 02/25/2023, 03/01/2023, 03/06/2023 and 03/10/2023, but administrator was still not providing the copy. It wasn't until 03/11/2023 that R1's representative received a copy. Text messages between R1's representative and the administrator were submitted to the department that were sent . The text messages dated 03/01/2023 shows R1's representative asking for paperwork and Administrator responded "Can I ask why we are so needing my paperwork? No families ask for this. But again it will be done when I can get it done".

Based on IB and LPA interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 is being issued today due neglect/lack of care & supervision led to resident sustaining a fracture (Refer to LIC 421IM).

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date.


Exit interview conducted with staff. A copy of the report and appeal right was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20230404133757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/03/2024
Section Cited
CCR
87705(c)(4)(A)
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In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement was not met as evidenced by
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Licensee is to comply with Title 22 Section 87705 at all times. Additionally, Licensee will submit a statement on how they will comply with this regulation to Community Care Licensing Division (CCLD) by 10/03/2024.
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Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1 had dementia which required that the facility had at least one night staff awake. Both S1 and S2 were asleep on 02/28/2023.
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Request Denied
Type A
10/03/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement was not met as evidenced by:
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Licensee is to comply with Title 22 Section 87468.2 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.
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Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The facility failed to develop a care plan based on the resident’s specific needs and to address the resident as a fall risk.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20230404133757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/03/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

This requirement was not met as evidenced by
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Licensee is to comply with Title 22 Section 87465 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.
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Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The staff found the resident on the floor between on 02/28/2023 at 6:30-7am and showed signs of pain. Administrator did not contact 911 until 2:30pm.
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Request Denied
Type B
10/03/2024
Section Cited
CCR
87507(e)
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Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.

This requirement was not met as evidenced by
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Licensee is to comply with Title 22 Section 87507 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.
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Based on interviews and records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Administrator failed to provide a copy of the admission agreement to R1's representative in a timely manner.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230404133757

FACILITY NAME:HOUSE OF GRACE 2FACILITY NUMBER:
198602863
ADMINISTRATOR:AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:2815 MESA DRIVETELEPHONE:
(626) 716-1033
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Edna Arbis - CaregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff restrained resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Edna Arbis (Caregiver) and explained the reason for the visit.

The investigation consisted of the following: On 04/05/2023, the Investigation Bureau (IB) accepted the complaint for investigation and assigned it to Investigator Douglass Real. On 04/06/2023, LPA Joe Katrdzhyan reviewed the file of Resident #1 (R1) and obtained copies of the following documents: Identification and Emergency Information Sheet, Admission Agreement, Agreements and Consent for Medical Treatment, Physician's Report, Resident Appraisal, Durable Power of Attorney, Unusual Incident/Injury Report, Centrally Stored Medication and Destruction Record, PRN Authorization Letter, Radiology Report, Facility Daily Logs/Notes, Transportation Invoice, Client Personal Property and Valuables, Resident Roster, Staff Roster. On On 09/03/2024, LPA Mora interviewed Administrator, Staff 1 (S1) and Staff 2 (S2) to gather additional information regarding the above allegations. During today's visit, LPA interviewed the second Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 (R1) representative, and Resident 2 - Resident 7 (R2 - R7). ( Continue to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion: 90
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20230404133757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOUSE OF GRACE 2
FACILITY NUMBER: 198602863
VISIT DATE: 10/02/2024
NARRATIVE
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Regarding allegation "Staff restrained resident in care" it is alleged that staff restrained R1 by sitting R1 on lazy boy recliner. The second Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. LPA observed three residents relaxing on the recliners. Two of them were sleeping. There was a staff in the living room observing them.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7