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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:23:52 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/02/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230602142710
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: 84DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Grace Park- LVNTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility failed to administer medication as prescribed
Facility refused resident access to telephone
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry to facility by LVN Grace Park and explained the reason for the visit.
The department received a complaint on 06/02/2023 and LPA Mendivil conducted an initial visit on 06/07/2023. LPA Mendivil obtained copies of medication administration records, physician’s report and admission agreements. Regarding the allegations Facility failed to administer medication as prescribed and Facility refused resident access to telephone, the investigation revealed the following:

It was alleged that Resident 1 (R1) was not receiving their medications and that cell phone access was restricted by the facility. Based on interviews with witnesses it was reported that R1's family retrieved R1's cell phone on 05/31/2023.
CONT on LIC 9099-C dated 08/02/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20230602142710
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 08/02/2023
NARRATIVE
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Per review of R1's physician report R1 is able to follow instructions and able to complete most activities of daily living including: bathing, dressing/grooming, feeding, toileting needs and able to manage cash resources. Per review of R1's admission agreement R1 is responsible for themselves. Based on interview with staff R1's family picked up their cell phone based on a conversation between R1 and family. Per interview with staff the facility did not take R1's phone away or restrict access to their phone. Per review of R1's medication administration record R1 was given all medications while at the facility, the only times that were missed were when R1 was in the hospital.

Based on interviews with 4 out of 4 residents stated they do not have issues with their medications, and they have received their medications. Based on interviews with 2 out of 2 staff the facility is providing medications to residents in a timely manner. Based on interviews with 4 out of 4 residents all state they have kept their belongings.

Therefore based on the preponderance of evidence through record review and interviews the allegations Facility failed to administer medication as prescribed and Facility refused resident access to telephone are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.

An exit interview was conducted and a copy of this report and confidential names list was provided

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
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