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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:25:57 AM

Document Has Been Signed on 08/02/2023 11:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Grace Park - LVNTIME COMPLETED:
11:45 AM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced Plan of Corrections visit in conjunction with complaint control #22-AS-20230706132440 and citations issued on 07/25/2023. LPA was greeted and granted entry into the facility by LVN Grace Park and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87506 (c)(1) pertaining to Residents Records has NOT been cleared. LPA Mendivil was able to confirm documents were not sent to the requestor. CIVIL PENALTY
ASSESSED.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with facility representative and a copy of LIC 421FC, LIC 809D and appeals rights were left at the facility.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2023 11:25 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 08/02/2023 at 10:44 AM
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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87506(c)(1)

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c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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Licensee to communicate with requestor and provide documents to requestor by POC due date.
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This requirement was not met as evidence by facility has not provided requestor with documents and has not shown proof to LPA.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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