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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 09/05/2023
Date Signed: 09/15/2023 10:38:38 AM

Document Has Been Signed on 09/15/2023 10:38 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
ORANGE COUNTY RO, 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: 92DATE:
09/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator/Licensee Erik Doan and Staff LVN Grace ParkTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced joint visit with IB Investigator Hector Quintanar for the purpose of conducting additional interviews for Complaint Control No. 22-AS-20230718165749 and 22-AS-20230531150652. LPA Tirre met with Licensee Erik Doan and LVN Grace Park and explained the reason for today’s visit.

During the visit, LPA, IB Investigator, and Licensee toured inside and outside physical plant of facility. LPA Tirre and Investigator Quintanar interviewed staff and resident. LPA requested and reviewed copies of the resident roster and staff roster.

During today's visit LPA observed broken glass on the ground outside of Memory care patio walkway. LPA observed feces on walkway wall. LPA also observed Memory care outside walkway had unsecured gate which led to back lot location where facility vehicles are parked. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 09/15/2023 10:39 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/15/2023 07:16 AM


Created By: Jenifer Tirre On 09/05/2023 at 03:33 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
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: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2023
Section Cited
CCR
87303(a)

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation was not met as evidence by: Based on LPA’s
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The Licensee will clean up broken glass immediately and provide photos as proof of cleaned walls by POC due date.
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observations, Licensee failed to keep the facility safe and sanitary as evidence by Broken glass observed unattended on the ground in Memory Care Unit and feces smeared on the wall. Both were observed accessible to dementia residents. This poses an immediate risk to the health and safety of residents in care.
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Type A
09/06/2023
Section Cited
CCR87705(h)

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Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This regulation was not met as evidence by: Based on LPA’s observations, Licensee
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The Licensee will secure self-closing latch on fence door by POC due date.
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failed to ensure that facility gate which led to back lot had a functioning self-closing latch. This poses an immediate risk to the safety of residents in care.
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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:Luz Adams
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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