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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 07/03/2023
Date Signed: 07/03/2023 04:41:21 PM

Document Has Been Signed on 07/03/2023 04:41 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:
07/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Erik Doan, Administrator (via telephoneTIME COMPLETED:
04:00 PM
NARRATIVE
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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 conducting a case management visit documenting deficiencies observed during the investigation of complaint 22-AS-20220629095332.

On June 23, 2023, LPA conducted a complaint follow-up visit at the facility. LPA requested resident records for resident R1, which facility staff and administrator were unable to locate and provide. LPA agreed to provide licensee with an additional delay to find where the documents were stored and provide them.

LPA followed up on this day, July 3, 2023. LPA spoke on the telephone with administrator Erik Doan who admitted that staff and himself had been unsuccessful in their attempts to locate the records, which included reaching out to former administrator Hyo Sook Kim. Former administrator is related to have said that the files should be stored along with the records of discharged and/or deceased residents, as resident R1 passed away at the facility on June 28, 2022.

As a result, a type B citation is issued to the facility on the attached form LIC809-D for failure to comply with Section 87506(e) of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with appeal rights were printed and provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
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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Document Has Been Signed on 07/03/2023 04:41 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/03/2023 at 04:07 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: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87506(e)

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The California Code of Regulations Section 87506(e) on Resident Records states that "Original records (...) shall be retained for a minimum of three (3) years following termination of service to the resident." This requirement is not met as evidenced by:
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Licensee to train all staff handling resident records of the necessity to maintain complete and accurate records for every person admitted and retain them at the facility for a minimum of three years following termination of service to the resident.
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The records requested by LPA Saborit-Guasch were unsuccessfully searched by facility staff who was eventually unable to provide them altogether. This poses a potential risk to the health, safety and personal rights of individuals in care.
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A copy of the training's curriculum and attendance will be provided to LPA before the Plan of Correction's due date of August 3, 2023.

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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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
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