<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:48:50 PM

Document Has Been Signed on 08/22/2023 02:48 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
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: 91DATE:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Facility Administrator- Erik DoanTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit in conjunction with complaint: 22-AS-20230620133756. LPA De Perio explained reason for visit, was greeted and granted entry by facility administrator (AD) Erik Doan.

LPA De Perio conducted a tour of the physical plant of the facility and obtained copies of records reviewed.

During the tour of the facility, LPA De Perio observed that the facility had possession of individual resident cell phones located in the facility chart room.

Upon conducting the record reviews, LPA De Perio observed 4 residents files that were missing physician reports.

For this visit, citations were issued.

An exit interview was conducted with AD Doan.

A copy of this report was provided and explained. Appeal rights were provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/22/2023 02:48 PM - It Cannot Be Edited


Created By: Celine DePerio On 08/22/2023 at 12:20 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2023
Section Cited
CCR
87458(a)

1
2
3
4
5
6
7
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As a plan of correction, licensee will organize resident files and obtain updated physican reports for the residents listed and will provide proof to LPA on or by 8/24/23.
8
9
10
11
12
13
14
Based on LPA's interviews, observations and record reviews, facility failed to obtain physician reports for R1, R2, R3, and R4,
This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/28/2023
Section Cited
CCR87468.2(a)(1)

1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to... Section 87468.1...residents...shall have all of the following personal rights:
(1) To have reasonable level of personal privacy...communications, telephone conversations...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As plan of correction, licensee will return resident cellphones to the rightful owner and will review the section citied and provide understanding to assigned LPA on or by 8/28/23.
8
9
10
11
12
13
14
Based on LPA's tour, interviews, observations and records reviews, facility took possession of a total of 6 resident's cellphones and placed it in a plastic container located in the staff office.
This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2