306090049-7-3-2023-22-AS-SSAS-CTQP6W-20230714110302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 07/03/2023
Date Signed: 07/03/2023 04:42:36 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
06/29/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220629095332

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: 82	DATE:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	04:01 PM
MET WITH:	Erik Doan, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not meet resident’s needs.

Facility staff did not follow doctor’s orders.

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 front desk staff after introducing himself and stating the purpose of the visit. Administrator Erik Doan was notified via telephone and arrived later to assist with the visit.

On July 6, 2022, LPA Sean Haddad conducted an initial complaint investigation visit at the facility.LPA met with Administrator (AD) Hyo Sook Kim, discussed the purpose of the inspection, and explained the allegations. During the inspection, LPA interviewed AD and requested and reviewed copies of resident roster, staff roster, resident files, and other pertinent records.

During a follow-up visit conducted on June 23, 2023, LPA requested resident R1's records kept at the facility after his passing on June 28, 2022. Facility staff was unable to provide the records on that day.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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 4

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
06/29/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220629095332

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:	DATE:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	04:01 PM
MET WITH:	Erik Doan, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff changed resident’s mailing address without authorization.

Facility did not notify responsible party of resident’s change in condition.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20220629095332

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: 07/03/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099-A

Regarding the allegation that Facility staff changed resident’s mailing address without authorization, the following has been concluded: Based on the staff interviews conducted and per facility policy under the Assisted Living Waiver (ALW), facility administrator notified the Social Security Administration of the fact that resident R1 had established residency at the facility after the admission agreement was signed and informed the Social Security Administration of the resulting change of address so relevant information necessary to the establishment of benefits under the ALW waiver could be conducted with no delay. As a result, the allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Regarding the allegation that Facility did not notify responsible party of resident’s change in condition, the following has been concluded: Based on records reviewed and interviews conducted, there is extensive documentation of exchanges and notification from facility staff to the resident's relatives and responsible party. The allegation is therefore deemed to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was printed and left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20220629095332

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: 07/03/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

LPA agreed to provide a deadline extension to facility administrator so that the records could be found. On July 3, 2023 a follow-up visit was conducted. Facility staff is still unable to provide the records at this time. A type B citation regarding this failure to comply with Title 22 regulations is being issued to the facility on a separate inspection report.

Regarding the allegation that Facility did not meet resident’s needs, the following has been concluded:
Based on interviews and records reviewed, resident R1 was admitted to the facility on June 8, 2022 upon discharge from St. Jude Hospital where he had been admitted for sepsis. At the time of admission, the resident did not have a hospice care service in place in addition to basic care and services provided at the facility, so facility staff resorted to using Home Health before an eventual hospice admission happened on June 22, 2022. Evidence provided shows that resident received adequate palliative care until his death six days later. As a result, this allegation is found to be unsubstantiated, meaning that 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.

Regarding the allegation that Facility staff did not follow doctor’s orders, the following has been concluded: Based on interviews and records reviewed, no evidence of non-observance of doctor's orders could be found besides a verbal disagreement with part of the resident's family regarding the quantity of oxygen to be dispensed and comfort measures provided to resident such as repositioning, documentation of which was provided during the initial complaint investigation. Therefore the allegation is found to be unsubstantiated, meaning that 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.

An exit interview was conducted and a copy of this report was printed and left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

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