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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:13:06 PM

Document Has Been Signed on 02/18/2022 03:13 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 69DATE:
02/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Erik DoanTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Licensee (LE) Erik Doan, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 05/01/2021. This is a change of ownership.

During the inspection, LPA and LE observed the following. Structure. This is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the clients. Facility telephone number is (562) 694-6515. Bedrooms Residents. The client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 120 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen. Toxins: observed in the locked storage rooms. Medication room and cabinets are locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection, LPA reviewed resident and staff file storage area. Fire clearance was approved by LA County Fire Department Inspector Eddie Martinez on 02/16/2022. Patio. Patio exit door is operational and unlocked. Patio has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with LE during today’s inspection. Facility is currently operating under the liability insurance of current facility BOK SENIOR HOTEL (306005182). LE will switch liability insurance to new facility once the application is approved.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 02/18/2022
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During the inspection, LPA and LE observed the following: (1) kitchen refrigerator temperature tested at 45 F degrees and freezer tested at 5 F degrees; (2) all stairways lacked evacuation chairs. LE agrees to correct these items and submit proof of completion to LPA Haddad on or before 02/22/2022.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. LE was informed the items listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to LE.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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