<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:48:56 PM

Document Has Been Signed on 04/12/2023 02:48 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
ORANGE & INLAND A/SC, 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: 77DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Erik Doan, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting deficiencies observed during the investigation of the allegation included in complaint 22-AS-20230119153437.

It was determined over the course of the investigation that half rails were in place on resident R1's bed when resident sustained a fall incident early in the morning of January 18, 2023. Based on interview with the facility's administrator and records reviewed during an initial investigation visit conducted in January, there were no physician orders in place to authorize the use of postural supports at the time. LPA observed the unit during today's visit. The half rail was noted to be present and mounted to the bed in the lowered position. LPA requested to review the resident's file for the presence of a doctor's order which was provided.

Additionally, it was determined that no incident report for the fall and subsequent hospitalization on January 18, 2023 were submitted by then administrator Hyo Sook Kim before the complaint investigation visit conducted on January 28, 2023. LPA provided a consultation with the current facility regarding the implications of making potentially false statements to a licensing agent.

Two Type B deficiencies are cited according to Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with appeals rights 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/12/2023 02:48 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 04/12/2023 at 12:23 PM
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2023
Section Cited
CCR
87608(a)(3)

1
2
3
4
5
6
7
The California Code of Regulations Section 87608(a)(3) states that: "A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record." This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain physician order for postural support for resident R1 and submit it to LPA before the Plan of Corrections due date.
8
9
10
11
12
13
14
Based on records reviewed, observation conducted and interviews, it was determined that half bed rails were in place without a physician report at the time of the fall incident on 01/18/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
Type B
04/12/2023
Section Cited
CCR87211(a)(1)(B)

1
2
3
4
5
6
7
The California Code of Regulations Section 87211(a)(1)(B) on Reporting Requirements states that: "A written report shall be submitted (...) within seven days (...) [for] Any serious injury (...) occurring while the resident is under facility supervision." This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee provided a late report during the facility visit in January, the deficiency is therefore cleared.
8
9
10
11
12
13
14
Based on records reviewed and interviews conducted, it was determined that licensee failed to submit an incident report prior to the facility inspection on 01/28/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2