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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:55:28 PM

Document Has Been Signed on 05/17/2022 04:55 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:HYO(MONICA)SOOK KIMFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 69DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Hyo (Monica) Sook KimTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit in conjunction with complaints visit 22-AS-20200325124107 and 22-AS-20200917155010. LPA Martinez met with Licensee Erik Doan and explained the reason for the visit. Administrator Hyo (Monica) Sook Kim arrived shortly after.

During the course of the complaint visit, LPA Martinez and Licensee Doan toured the inside and outside of he facility. LPA Martinez noted a wheelchair laying on its side blocking the exit gate door on the outside of first floor by Memory Care. Gate door was also tied with a cloth at the top (pictures taken). Licensee Doan did not have an explanation for it other than they had a resident from Memory Care AWOL some days ago.

Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with AD Monica Kim and a copy of the report will be emailed along with Appeal Rights.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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Document Has Been Signed on 05/17/2022 04:55 PM - It Cannot Be Edited


Created By: Lydia Martinez On 05/17/2022 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited
CCR
87203

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Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by:
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Administrator states the staff will be trained in Fire Safety, Evacuation and Resident Rights. Administrator agrees to ensure the facility exits will not be blocked for any reason. Administrator to forward proof of correction by POC due date.
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LPA and Licensee observed a wheelchair laying on its side blocking an exit gate door on the outside of the first floor by Memory Care. Gate door was also tied with a cloth at the top. This posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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