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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 02/22/2022
Date Signed: 02/22/2022 02:50:21 PM

Document Has Been Signed on 02/22/2022 02:50 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: 68DATE:
02/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Erik DoanTIME COMPLETED:
03:05 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. This is the second pre-licensing inspection. Please see LIC809 dated 02/18/2022.

During today’s inspection, LPA observed the following items have been corrected: (1) kitchen refrigerator temperature tested at 38 F degrees and freezer tested at 0 F degrees; (2) there are now evacuation chairs at the top of all 5 stairways.

LPA explained the process of this application and about the post licensing inspection once the facility is licensed. LE was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. Component III was completed with LE during the initial pre-licensing inspection. 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: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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