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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:01:45 PM

Substantiated


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
04/18/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220418111625
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: DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident went AWOL from the facility.

Facility floor is in disrepair.
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 into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Facility administrator was notified by telephone and informed of the report.

An initial investigation visit was conducted on April 27, 2022. LPA Sean Haddad inspected the facility, interviewed one resident and three staff members. LPA also requested and reviewed copies of resident roster, staff roster, and facility records.

Regarding the allegation that Resident went AWOL from the facility, the following has been concluded: On April 17 2022, facility became unable to locate resident R1 at approximately 2:30PM. After being notified of the resident's absence, the facility administrator called the La Habra Police Department.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
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
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
04/18/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220418111625

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: DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
3
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5
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8
9
Facility door/gate is in disrepair.
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 into the investigation of the allegation listed above. LPA was greeted and granted entry by facility administrator after introducing himself and stating the purpose of the visit.

An initial investigation visit was conducted on April 27, 2022. LPA Sean Haddad inspected the facility, interviewed one residents and three staff members. LPA also requested and reviewed copies of resident roster, staff roster, and facility records.

Regarding the allegation that Facility door/gate is in disrepair, the following has been concluded: During the initial visit on April 27, 2022, LPA Sean Haddad LPA tested the delayed egress door twice and each time an alarm sounded properly.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220418111625
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: 06/16/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A

The three outside exit gates were all confirmed to be functioning properly. The two outside gates accessible to residents are kept locked. A third gate only accessible by going through a delayed egress door (and triggering an alarm) is unlocked as a fire exit. It was suggested during the visit that resident R1 may have exited the facility through an unlocked sliding window for a unit outside memory care that leads into the locked outside area. Therefore 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 that the alleged violation did occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220418111625
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: 06/16/2023
NARRATIVE
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CONTINUED ON FORM LIC9099

After receiving the missing person report, law enforcement conducted a search for the missing resident. Facility staff S1 was informed by a relation of the whereabouts of resident R1 approximately one hour later. Resident was found at a nearby gas station and brought back to the facility. Local law enforcement was notified that resident was no longer missing at this time. Facility administrator stated to LPA Haddad that she had not reported the elopement to the Department because R1 was found so quickly and claimed to not have been aware of the reporting requirements. Administrator however reported the elopement and its resolution to law enforcement and to R1's responsible party. Based on the interview conducted, the allegation is deemed Substantiated, meaning that the preponderance of evidence standard has been met. A Type A citation is issued on the attached form LIC9099-D and civil penalty is assessed per Title 22 regulations.

Regarding the allegation that Facility floor is in disrepair, the following has been concluded: During the tour of the physical plant conducted during the initial investigation visit, LPA Haddad observed brand new hardwood floor in the memory care unit. Visual inspection shows the floor is recently installed, however due to a probable installation error, the material bunches up in places and creases up, thus creating a fall hazard. A Type B citation is issued on the attached form LIC9099-D. The floor defects are confirmed to have been corrected since the initial visit, therefore the deficiency is cleared.

An exit interview was conducted and a copy of this report along with appeal rights was made and provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20220418111625
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
HSC
1569.312
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Health and Safety Code section 1569.312 provides that every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety.
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Licensee to provide updated training on the importance of securing all ways of ingress and egress into the memory care unit.
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Based on interviews conducted, this requirement is not being met as evidenced by the fact that resident R1 was able to leave the facility unattended in spite of being admitted to the secure memory care unit.
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Type B
06/16/2023
Section Cited
CCR
87303(a)
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California Code of Regulations Section 87303(a) on Maintenance and Operation states that: "The facility shall be clean, safe, sanitary and in good repair at all times." Based on observation conducted at the facility, this requirement is not met as evidenced by:
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Licensee to ensure that the flooring in all areas of the facility is safe and in good repair.
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Floor material in the memory care unit bunches up in places and creases up, thus creating a fall hazard.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5