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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:59:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/20/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230620133756
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: 99DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Assistant Administrator - Anna JungTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff did not adequately supervise resident resulting in resident wandering from the facility and sustaining multiple injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 6/20/23. LPA arrived at the facility and explained the purpose of today’s visit, was greeted and granted entry by staff on duty. Facility administrator (AD) Erik Doan was notified but was unable to be present during today’s visit. LPA De Perio met with assistant facility administrator Anna Jung.

The complaint was investigated by the Department which involved interviews and record review.

It is alleged that facility staff did not adequately supervise residents resulting in resident wandering from the facility and sustaining multiple injuries.The investigation revealed that resident (R1) was admitted to the facility on May 4, 2023, of which facility administrator and staff were informed that R1 was a fall risk but not an elopement risk because there was no history of R1 eloping. On May 4, 2023, a discharge summary report was completed by the Pasadena Care Center prior to R1 being admitted to the facility and it revealed that R1 is diagnosed with unspecified dementia.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 5
Control Number 22-AS-20230620133756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 11/02/2023
NARRATIVE
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Upon admission, R1’s physician report dated for May 5, 2023, indicated that R1 was non-ambulatory. R1 began receiving Home Health Services on May 6, 2023, and was discharged from Home Health Services June 5, 2023, due to no further skilled care needed. R1 had several diagnoses such as: Type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild unspecified dementia, unspecified severity, history of falling.

Interviews conducted with the facility staff stated that R1 liked to walk around the facility but never made any attempts to leave. On June 18, 2023, staff (S1) conducted a room check at 8:30PM and observed R1 was sleeping. S1 returned to R1’s room to conduct a second check between 10:30PM-11:00PM and did not observe R1 in the room. S1 observed that R1’s sliding glass door which led to the street was open. S1 notified staff on duty and La Habra Police Department (LHPD). Per LHPD report dated June 18, 2023, the R1 was found four hours later with facial injuries by Whittier Police Department and taken to the hospital.

R1 was hospitalized and upon admission at the hospital, R1 was observed with blunt trauma to face and per-orbital fracture. The following injuries were noted on R1: multiple depressed fractures at the left zygoma, lateral wall of the left orbit, and left maxillary sinus, slightly displaced left orbital floor fracture, left periorbital/facial soft tissue injury, blood products in the left maxillary sinus. It was observed that R1’s face had extensive dark bruising on left temple area, below left eye and on left chin and cheek and multiple scratches/marks around R1’s nose, mouth, chin, and bruising on left side of R1’s nose.

Eight days later, the facility submitted an incident report to Community Care Licensing on June 26, 2023, regarding R1’s June 18, 2023 elopement. On June 23, 2023, an interview was conducted with the facility administrator (AD) who stated that R1 did not have an alarm on their door and was unsure if the facility documented watch logs per resident. The day following the interview, AD provided the Department with a document titled “Watch Log” starting from June 18, 2023, which was the day R1 eloped, and was noted for the times of 6:00AM to 11:00PM. It was observed that there was a staff initial next to every hour. A follow-up interview was conducted with the staff members who had initials on the Watch Log. S1 admitted to never seeing or using a Watch Log, and also denied of initialing a Watch Log document.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230620133756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 11/02/2023
NARRATIVE
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An interview was conducted with staff 2 (S2) who provided AD the Watch Log, and S2 stated that the log was for the facility’s own personal use and that S2 was unaware it was sent to the Department. S2 then stated the log was made as an example for AD to possibly use in the future. When AD was asked to explain how the log was accidentally sent to the Department, AD stated that AD was unaware if the facility documented room checks, and stated the document was for S2’s personal documentation and was not meant to be disseminated. It was also observed that the document was not accurate because the initials of S1 indicated that S1 checked on R1 between 9:00 PM and 10:00 PM, however an interview was conducted with S1, who denied the of initiating a document. This document was later determined to be a false document that was completed by S2, therefore it became a concern that there may be additional documents that were provided that also may have been falsified. Upon additional investigation involving interviewing R1’s physician, it was determined that R1’s physician’s report dated for May 5, 2023 was falsified. The report had the physician’s name handwritten on it with the exam date of May 5, 2023, however the indicated physician confirmed that the report was not signed by him as R1 had not been evaluated by the physician until June 18, 2023.

Per falsified physician report provided by the facility dated May 5, 2023, R1 was reported to only have Mild Cognitive Impairment, is unable to leave the facility unassisted, is non-ambulatory, and that R1 did not have dementia. However, the Pasadena Care Center discharge summary dated for May 4, 2023 and the admission summary from Whittier Hospital dated for June 19, 2023, indicated that the R1 is diagnosed with dementia.

During the investigation, evidence shows that the physician’s report was falsified, because the physician denied of ever evaluating R1 on May 5, 2023 and that the physician report the facility presented did not align with the diagnoses specified on the Pasadena Care Center documents. It was determined that R1 did not have a medical exam prior to being admitted to the facility, therefore, the facility was unaware of the level of care R1 required, resulting in R1 eloping and sustaining multiple injuries.

Based on interviews which were conducted by the Department, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230620133756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 11/02/2023
NARRATIVE
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See LIC9099D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49.

An exit interview was conducted with assistant administrator Jung.

A copy of this report, and appeal rights were provided and explained.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20230620133756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services
(f) Basic services shall... 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:
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As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/2023.
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Based on the documents obtained and interviews conducted, the facility did not obtain a proper medical evaluation for the resident, therefore was unaware of the care and supervision the resident needed, resulting into the resident wandering out of the facility and sustaining injuries. This poses an immediate health and safety risk to 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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5