306090049-11-9-2023-22-AS-MSTC-CXJMFT-20231113083450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 11/09/2023
Date Signed: 11/09/2023 05:53:52 PM

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 VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	HYO(MONICA)SOOK KIM		FACILITY TYPE:	740
ADDRESS:	1100 E. WHITTIER BLVD.		TELEPHONE:	(562) 694-6515
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 106	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	04:04 PM
MET WITH:	Anna Jung- Administrator Assistant		TIME COMPLETED:	05:57 PM

ALLEGATION(S):

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Resident went AWOL from the facility due to lack of care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Administrator Assistant Anna Jung and explained the reason for the visit.

During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including the Physician Report (LIC602) dated April 29, 2022, Unusual Incident/Injury Report dated May 1 2022, Appraisal/Needs and Services Plan dated April 29, 2022, for Resident 1 (R1), Personnel Report (LIC500), Resident Roster, Fire Safety Inspection Request dated February 16, 2023 and Plan of Operation related to care of persons with Dementia. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following: R1 was admitted to the facility officially on April 29, 2022, as per signed admission agreement provided by the facility staff; however, R1 was not physically present at the facility until the next day
CONTINUED ON 9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 4

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: 11/09/2023

NARRATIVE

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on April 30, 2022 when R1 started to reside at the facility. Prior to being admitted to the facility, R1 had previously been admitted to two other board and care facilities and eloped from both homes within 24 hours of being admitted. Interviews with facility staff confirmed the facility received R1’s hospital discharge paperwork from Kaiser Hospital on April 29, 2023, at 11:15 AM what is approximately 10 hours prior to R1 residing at the facility. Although the Licensee reported not reading the paperwork and that the hospital had dropped R1 off blindly, interviews with the facility Administrator Hyo Sok Kim disclosed that they were aware of R1’s exit seeking behaviors and combative and believed R1 would be easily controlled using medications. Kaiser Hospital discharge records dated April 14, 2022, confirmed R1’s diagnosis of dementia with behavioral disturbances and exit seeking behaviors.

On May 6, 2022, two of three staff interviewed reported that R1 had become combative with staff and exited the facility memory care unit. At the time of the incident, staffing records show only Staff 1 (S1) was working at the facility memory care unit. After exiting the memory care unit, R1 continued to the facility entrance. At approximately 11:30 AM R1 eloped from the facility unassisted. Despite knowing R1’s history and seeing R1 walk out of the facility, no staff followed behind to provide R1 with supervision when exiting. S2 contacted La Habra Police to report R1 missing at 1:49 PM, approximately three hours after R1 left the facility. On May 4, 2022, R1’s remains were discovered by the San Bernadino Sheriff’s Department (SBSD) after being struck by a vehicle driver on the 10 freeway. The autopsy report obtained lists R1’s cause of death as multiple blunt force injuries, instantaneous.

Despite being made aware of R1’s behaviors and history of exit seeking, the facility still chose to admit R1 to the facility as agreed upon per signed admission agreement. By accepting R1 to the facility, the facility agreed to provide care and supervision as necessary to meet R1’s needs. Facility Administrator Hyo Sok Kim admitted she had filled out R1’s paperwork prior to R1 being admitted and assessed. Despite being provided with R1’s history of exit seeking and behaviors, R1 failed to be properly assessed and later it was determined R1 was not a good fit for the facility.

Licensee Eric Doan stated the facility had not received R1’s paperwork prior to being admitted and that the hospital had dropped R1 off after hours and on the weekend. This was a false statement as investigation revealed that the facility did in fact received R1’s paperwork prior to R1 being admitted. They were expecting R1 in advance of them being placed with the facility but failed to properly conduct an assessment.

CONTINUED ON 9099-C...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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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: 11/09/2023

NARRATIVE

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On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with S2. No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing.

Despite signing the agreement, the facility failed to provide proper supervision resulting in R1 eloping from the facility and dying three days later. Therefore, based on interviews conducted and records reviewed the allegation that Resident went AWOL from the facility due to lack of care and supervision has been deemed Substantiated.

The facility is being cited 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(e)

An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights were left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 11/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/10/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services (f)Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not	1 2 3 4 5 6 7	Per Administrator Assistant facility will develop a Plan of Action to prevent future elopements and will conduct an in-house training with staff. Administrator Assistant to email proof to LPA by POC due date.
	8 9 10 11 12 13 14	provide care and supervision to R1 resulting in R1 eloping from the facility and dying. Prior to being admitted the facility was made aware of R1’s exit seeking behaviors and still chose to admit R1 to the facility. This poses an immediate risk to health risk to residents in care. An immediate civil penalty of $500 is being assessed.	8 9 10 11 12 13 14
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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