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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:31:59 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: 92DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Crysel Santos-AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate security systems
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Administrator (AD) Crysel Santos and explained the reason for the visit.

This agency has investigated the complaint alleging that facility has inadequate security systems. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the investigation LPA reviewed documents including the Fire Safety Inspection Request dated 02/16/22. Per Fire Safety Inspection Request under special conditions, it states Memory Care and delayed egress. LPA also reviewed the Plan of Operation related to care of person with Dementia. Per Plan of Operation all facility exits are equipped with operational auditory alarms if exiting may pose a hazard to residents. During the initial visit on 05/06/22 LPA Haddad and AD tested the delayed egress door located at the end of the hallway in the Memory Care unit. During a subsequent visit on 06/19/23 LPA and AD tested the same delayed egress door.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
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 3
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: 09/11/2023
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
26
27
28
29
30
31
32
On both dates the alarm rang when the exit was pushed and after pushing for 10 seconds the door opened. LPA observed as staff responded to the delayed egress alarm within three to five seconds. During the course of the interviews AD stated that the alarms get tested once a month. Per AD staff redirect residents who cannot leave unassisted, and staff try to provide what the residents need in order to de-escalate the situation. However, records reviewed by LPA Ramirez included the Unusual Incident/Injury Reports (UIIRs) dated 05/02/22 for Resident 1 (R1), dated 09/17/22 for R2 and dated 06/19/23 for R3. Per UIIRs R1 eloped from the facility on 05/01/22, R2 eloped from the facility on 09/17/22 and R3 eloped from the facility on 06/18/23. The facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted. Even though the facility has security systems, the security systems have proved inadequate as evidence by multiple residents eloping from the facility unsupervised.

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 has inadequate security systems 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 AD Santos 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: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 09/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Three of three UIIRs reviewed by LPA indicate that the residents left the
1
2
3
4
5
6
7
Licensee to submit a written plan to ensure basic services including care and supervision are provided to residents in care at all times by POC due date.
8
9
10
11
12
13
14
facility unassisted. Therefore, the facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3