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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 08/01/2023
Date Signed: 08/01/2023 10:50:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/02/2022 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220502151946
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: 81DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff-Rachel ChungTIME COMPLETED:
11:07 AM
ALLEGATION(S):
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Facility is operating understaffed
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 05/02/22. LPA was greeted and granted entry into the facility and met with Staff Rachel Chung and explained the reason for the visit. Administrator (AD) Erik Doan was notified via telephone.

This agency has investigated the complaint alleging that facility is operating understaffed. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Three of eleven individuals interviewed denied the allegation. Five individuals reported that hiring more staff would be helpful and the remaining three individuals were not able to be contacted by LPA. As of 06/19/23 facility reported a total census of eighty-three residents. Records reviewed by LPA Ramirez included the staff schedule. On average there are four caregivers and one medication technician for the morning shift (6:00 AM-2:30 PM), four caregivers and one medication technician in the evening (2:30 PM-11:00 PM) and three caregivers for the night shift (11:00 PM-6:30 AM) for eighty-three
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 6
Control Number 22-AS-20220502151946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 08/01/2023
NARRATIVE
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residents in care. Per AD 61 residents can leave the facility unassisted, 22 residents have a diagnosis of dementia and none of the residents are bedridden. During interviews with residents, it was reported that hiring more staff would be beneficial for both caregivers and residents. It was reported via interviews that hiring more staff would be beneficial because residents would have better care and supervision and/or that because the residents require a lot of care and attention. Records reviewed by LPA Ramirez included the Unusual Incident/Injury Report (UIIR) dated 05/02/22 for Resident 1 (R1). Per UIIR R1 pushed the door, started running and left the facility. During interviews with staff, it was reported that no one followed R1 but that a caregiver noted which direction R1 went. Per UIIR R1 left the facility unassisted on 05/01/22 at 11:49 AM. During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 04/29/22 for Resident 1 (R1). Per Physician Report R1 is not Able to Leave Facility Unassisted.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility is operating understaffed is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.



An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20220502151946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of
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Per AD the facility has been hiring more staff. Licensee to provide an updated Personnel Report (LIC500) by POC due date.
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personal assistance and care...
This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6