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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 11/09/2023
Date Signed: 11/09/2023 06:37:30 PM

Document Has Been Signed on 11/09/2023 06:37 PM - 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: 106DATE:
11/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:58 PM
MET WITH:Anna Jung-Administrator AssistantTIME COMPLETED:
06:30 PM
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit. LPA was greeted and granted entry into the facility by Administrator Assistant Anna Jung.

On this day an amended report of LIC809-D dated 9/11/23 was served to the facility. Changes made to the report included a change to requested plan of correction to meet Title 22 requirements. Updated POC request is due by 11/16/23.
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.

LIC809 (FAS) - (06/04)
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