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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:22:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/07/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220907180032
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: 78DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hyo Sook KimTIME COMPLETED:
03:37 PM
ALLEGATION(S):
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Staff restrained resident
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegation. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection. The investigation into the allegation that Staff restrained resident revealed the following: During the course of the investigation, LPA conducted a health and safety check on Resident #1 (R1), interviewed AD, staff, and witnesses, and requested and reviewed copies of the resident roster, staff roster, and training records.

A witness stated in interviews that on 08/24/22 they observed R1 in the activity room tied to their wheelchair with a scarf, they were told by R1 that staff had tied R1 to the wheelchair because they keep trying to get up from the wheelchair, and they called AD over who immediately removed the scarf from R1. When interviewed, AD admitted that this incident occurred as reported, but stated they were not aware that R1 had been tied to their wheelchair.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
Control Number 22-AS-20220907180032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2022
NARRATIVE
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AD identified Staff #1 (S1) as the staff who had tied R1. In interviews, S1 stated that earlier that morning R1 had fallen from their wheelchair, that R1 kept trying to stand but was not able to stand or walk, so S1 used a scarf to secure R1 to their wheelchair for R1’s safety because the wheelchair did not have a seatbelt and R1 did not know that it was improper to tie residents to wheelchairs. S1 stated that they now know not to do it again. AD stated that shortly after the incident they trained staff to never to tie residents to their wheelchairs and to report any such incidents. On 09/14/22, LPA conducted a health and safety check on R1 and observed R1 to be in good health and good spirits.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20220907180032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights … (a) In addition to the … (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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Licensee stated they already trained all caregivers never to tie residents to wheelchairs and to report any such incidents. Licensee provided proof to LPA during the inspection.
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Based on interviews, the licensee did not ensure R1 was free from neglect, punishment, and physical abuse when a staff member tied R1 to their wheelchair, which poses an immediate personal rights and safety risk to residents in care.
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Licensee stated they will train all other employees never to tie residents to wheelchairs and to report any such incidents and to provide proof of training to LPA within 5 days of POC due date.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/07/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220907180032

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: 78DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hyo Sook KimTIME COMPLETED:
03:37 PM
ALLEGATION(S):
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9
Lack of care and supervision
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegation. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection. The investigation into the allegation of Lack of care and supervision revealed the following: During the course of the investigation, LPA conducted a health and safety check on Resident #1 (R1), interviewed AD, staff, and witnesses, and requested and reviewed copies of the resident roster, staff roster, and training records.

A witness stated in interviews that on 08/24/22 they observed 9 residents in the activity room watching TV and singing without supervision and they called AD over who quickly brought a staff member to supervise the residents. The witness stated that they observed the residents unsupervised for a few minutes. When interviewed, AD stated that they had 2 staff out that day, but the facility was not short staffed. AD stated that the caregivers were going back and forth moving residents to the activity room from their rooms, that the activity had not yet started, and that the residents in the activity room were waiting for the activity to start.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220907180032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2022
NARRATIVE
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AD stated that the staff conducting the activity arrived within minutes of AD arriving to the activity room. While the residents may have been left alone in the activity room, they were only left alone for a few minutes and staff were going back and forth to the activity room bringing residents to the activity and the staff conducting the activity arrived shortly thereafter.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5