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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:35:37 AM

Document Has Been Signed on 09/11/2023 11:35 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:POCUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Crysel Santos-AdministratorTIME COMPLETED:
11:51 AM
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
On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20220502151946 and citations issued on 08/01/2023. LPA was greeted and granted entry into the facility by Administrator (AD) Crysel Santos and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87411(a) pertaining to Personnel Requirements - General
has NOT been cleared. Per AD the POC was not sent to LPA. The POC was due on 08/11/23.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Santos and a copy of this report along with the LIC809D and 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
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 11/09/2023 06:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/09/2023 01:03 PM


Created By: Alvaro Ramirez Jr. On 09/11/2023 at 10:57 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
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 A
11/16/2023
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of
1
2
3
4
5
6
7
Per Administrator Assistant the facility will be using agengy staff as needed, facility will be offering overtime as needed and facility will develop a Plan of Action to have sufficient personnel at all times. Administrator Assistant to email proof to LPA by POC due date.
8
9
10
11
12
13
14
personal assistance and care...
This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave 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.
SUPERVISOR'S 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


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