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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 06/30/2023
Date Signed: 06/30/2023 12:52:11 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
05/31/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230531150652
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: 82DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Erik Doan-AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not allow resident to have visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 05/31/23. LPA was greeted and granted entry into the facility and met with Administrator (AD) Erik Doan and explained the reason for the visit.

This agency has investigated the complaint alleging that staff did not allow resident to have visitors. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Eight of ten individuals interviewed denied the allegation. As for the remaining two individuals, one individual confirmed the allegation and the other could not be interviewed as they were on vacation. During the investigation LPA reviewed documents including the Visitor Sign In/Out Log dated 04/29/23 through 06/18/23. Per Visitor Sign In/Out Log on 05/14/23 a visitor for Resident 1 (R1) sign in at 7:45 AM and sign out at 8:10 AM. On average per day one to thirteen visitors signed the Visitor Sign In/Out Log between May and June 2023.
Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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 3
Control Number 22-AS-20230531150652
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: 06/30/2023
NARRATIVE
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During the initial visit on 06/01/23 and today’s visit LPA observed a sign with the visitation hours posted in the main entrance of the facility. During interviews with staff and residents it was reported that family is allowed to visit any time and/or that there are no restrictions when it comes to family visiting. During the course of the interviews AD stated that friends and family are allowed to visit from 8:00 AM-5:00 PM.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Therefore, the allegation has been deemed to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred.

LPA Ramirez conducted an exit interview with AD Doan, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3