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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 06/30/2023
Date Signed: 06/30/2023 12:57:36 PM

Document Has Been Signed on 06/30/2023 12:57 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: 82DATE:
06/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Erik Doan-AdministratorTIME COMPLETED:
01:15 PM
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to deliver amended reports dated 05/06/22 and 06/19/23 for complaint 22-AS-20220502151946 and reports dated 06/01/23 and 06/19/23 for complaint 22-AS-20230531150652. LPA met with Administrator (AD) Erik Doan and explained the purpose of the visit.

During the inspection, LPA and AD discussed the previously delivered findings and the amended findings and LPA delivered the amended report.



An exit interview was conducted with AD Doan and a copy of this report was provided at the time of exit.
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.

LIC809 (FAS) - (06/04)
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