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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:33:47 AM

Document Has Been Signed on 09/11/2023 11:33 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:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Crysel Santos-AdministratorTIME COMPLETED:
10:42 AM
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to deliver an amended report dated 08/01/23 in conjunction with complaint 22-AS-20220502151946. LPA was greeted and granted entry into the facility and met with Administrator (AD) Crysel Santos.


An exit interview was conducted with AD Santos and a copy of this report was provided at the time of exit.
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.

LIC809 (FAS) - (06/04)
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