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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 09/15/2023
Date Signed: 09/15/2023 10:20:28 AM

Document Has Been Signed on 09/15/2023 10:20 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:CRYSEL SANTOSFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 93DATE:
09/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator Crysel SantosTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit on this day to conduct a case management to follow up on plan of correction (POC) for citations issued during a previous inspections issued by the Department dated 08/31/2023 and 09/05/2023. During today’s visit LPA witnessed the following:

1569.605 Health and Safety. All residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000). During the investigation conducted on 08/31/23, it was determined the Licensee failed to provide the full liability insurance policy as requested by the Department. The POC due date was 9/11/23. Per POC, the Licensee was to provide the Department with a copy of their full liability insurance policy by the above POC due date. On 9/11/23 the Licensee submitted a copy of a full liability insurance policy; However, the ensured entity listed on the liability insurance policy is for Bok Senior Hotel, Inc. not the Licensee Grace Retirement, LLC. In addition, exclusions listed in the liability insurance policy does not meet regulatory requirements to cover injury to residents and guests in the required amounts as listed above. On today’s date LPA verified POC provided does not meet requirements. Therefore, the POC was not received by POC due date of 9/11/23. CIVIL PENALTY ASSESSED FOR $400 FOR FAILURE TO CORRECT. A $100 daily civil penalty will continue to accrue until this deficiency is cleared.

87303(a) 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. During the investigation conducted on 09/05/23, it was determined the Licensee failed to keep the facility safe and sanitary due to broken glass observed unattended on the ground in Memory Care Unit and feces smeared on the wall. POC due date was 9/06/23. Per POC, the Licensee was to clean up broken glass immediately and provide photos as proof of cleaned walls. As of 09/06/23 the Licensee has submitted proof of correction as listed above. On today’s date LPA verified

CONTINUED ON 809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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
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
VISIT DATE: 09/15/2023
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POC provided does meet requirements. Therefore, the POC Deficiency is cleared.

87705(h) 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. During the investigation conducted on 09/05/23, it was determined the Licensee failed to ensure that facility gate which led to back lot had a functioning self-closing latch. POC due date was 9/06/23. Per POC, the Licensee was to secure self-closing latch on fence door by POC due date. As of 09/06/23 the Licensee provided photo as proof of correction as listed above. On today’s date LPA verified POC provided does not meet requirements. Therefore, the POC was not received by POC due date of 9/06/23. CIVIL PENALTY ASSESSED FOR $900 FOR FAILURE TO CORRECT. A $100 daily civil penalty will continue to accrue until this deficiency is cleared.

An exit interview was conducted and Administrator Santos and a copy of this report and civil penalty assessment and appeal rights were provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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