<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 04/23/2026
Date Signed: 04/23/2026 03:48:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator William Vanegas
COMPLAINT CONTROL NUMBER: 22-AS-20260320114355
FACILITY NAME:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR:MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 5DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Quy Mai (Caregiver) TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff do not ensure that facility is clean and sanitary
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering the findings of the above-mentioned allegation. LPA was greeted and granted entry into the facility by caregiving staff after introducing himself and stating the purpose for the visit. LPA began to explain the detailed information of the findings. LPA Vanegas explained the following. LPA conducted the initial 10-day visit on March 30, 2026. LPA conducted a tour of the interior and exterior of the facility and gathered photo evidence in relation to the above-mentioned allegation. Additionally, LPA interviewed two of two staff and interviewed the complainant in regard to the above-mentioned allegation.
In regard to the allegation stating Staff do not ensure that the facility is clean and sanitary the following has been concluded: LPA conducted two staff interviews. No resident interviews were conducted due to all residents being asleep at the time of unannounced inspection date and time. Two out of two staff confirmed the allegation being investigated. Staff 1 (S1) states that they have encouraged Administrator to organize items in the facility, and that some of the items laying around the facility belong to a resident who does not have a storage unit where they can store them. CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
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 3
Control Number 22-AS-20260320114355
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470
VISIT DATE: 04/23/2026
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
26
27
28
29
30
31
32
Continuation from LIC9099

S2 admitted to having these items around the facility due to wanting to repair them and have them be used for the benefit of the residents in care. Per LPA’s observations many miscellaneous items were observed scattered throughout the exterior of the facility, Additionally LPA observed side exit routes to have items along the walls of the exit routes which partially obstructs the side exit routes. LPA observed that although the side exit is partially obstructed residents are still capable of exiting through the side exit.

Based on the observations made by LPA, photographic evidence, and interviews conducted with staff, the preponderance of evidence standard has been met therefore the allegation is substantiated. A deficiency will be cited per Title 22 division 6 chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260320114355
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACES HOME
FACILITY NUMBER: 306005470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2026
Section Cited
CCR
87308(C)
1
2
3
4
5
6
7
87308: Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. Based on observations made
1
2
3
4
5
6
7
Administrator agrees to clear out all debris and obsturctions that were observed to be on the premices durring LPA's inspection. LPA will conduct a plan of correction visit to confirm that correction has been made by P.O.C due date.
8
9
10
11
12
13
14
by LPA the Administrator failed to ensure that sufficient storage space was made available to store items, and allow for a clean and sanitary environment for residents in care which poses an immediate personal rights violation for residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3