306090049-4-12-2023-22-AS-SSAS-CQUULB-20230413154027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:47:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/19/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230119153437

FACILITY NAME:	GRACE RETIREMENT VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	HYO(MONICA)SOOK KIM		FACILITY TYPE:	740
ADDRESS:	1100 E. WHITTIER BLVD.		TELEPHONE:	(562) 694-6515
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 77	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Erik Doan, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not respond to resident's call for help in a timely manner.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegation listed above. LPA was greeted and granted entry by nursing staff before explaining the purpose of the visit and listing the allegation. Administrator Erik Doan was notified by telephone and arrived later to assist with the visit.

An initial complaint investigation visit was conducted on January 26, 2023. LPA accompanied by then administrator Hyo Sook Kim toured the unit assigned to resident R1. Resident records reviewed and an interview of the caregiver on staff in the early hours of January 18, 2023 was conducted by telephone. Additional interview conducted with facility administrator.

A subpoena of medical records from resident R1's trip to the emergency department at UCI Hospital was submitted and records reviewed. Additional witnesses interviews were conducted via telephone.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230119153437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE RETIREMENT VILLAGE	FACILITY NUMBER: 306090049
	VISIT DATE: 04/12/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

During today's visit, LPA requested to obtain the facility's current census. A tour of the physical plant and unit assigned to resident R1 was additionally conducted.

Regarding the allegation that Facility did not respond to resident's call for help in a timely manner, the following has been concluded: In the early hours of January 18, 2023, resident R1 suffered a fall incident in his bedroom at the facility. The fall occurred in the interval between two rounds being conducted, between the hours of 1:40am and 5:00am as certified in the log maintained by staff to document resident checks by the overnight staff. The exact time of occurrence could not be assessed from the evidence gathered. Resident R1 was found by staff member S1 and assisted back into bed. Later that day, resident kept displaying signs of pain, which led to 911 being called. Resident R1 was assessed at the facility and transported to the Emergency Department at UCI Hospital before being released to a Skilled Nursing Facility with a diagnosis of a compression fracture of the seventh thoracic vertebra.

At the time of the present visit, the resident is stated to have been admitted back into the facility and appears to be doing well.

The evidence gathered did not allow to make a precise determination of the time interval between the fall and assistance being provided to the resident. As a result, the allegation is deemed to be Unsubstantiated,meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided and left to facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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