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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 07:04:42 PM

Document Has Been Signed on 11/09/2023 07:04 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:
06:31 PM
MET WITH:Anna Jung-Administrator AssistantTIME COMPLETED:
07:19 PM
NARRATIVE
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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 Assistant Administrator Anna Jung and explained the reason for the visit. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency.

During course of the investigation it was determined Resident 1 (R1) was admitted to the facility on April 30, 2022. However, R1’s admission agreement was signed and dated April 29, 2022. Facility AD 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 was 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 receive 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. On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with the Staff 2 (S2). No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing.

The following deficiencies are being cited per Title 22 Division 6.

An exit interview was conducted, and a copy of this report 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
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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Document Has Been Signed on 11/09/2023 07:04 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/09/2023 at 06:41 PM
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
, 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
87456(a)

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(a) Evaluation of Suitability for Admission. Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:..conduct an interview…perform a pre-admission appraisal…obtain and evaluate a recent medical assessment…This regulation
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Per Administrator Assistant the facility will develop a Plan of Action to evaluate residents suitability prior to being admitted to the facility. Administrator Assistant to email proof to LPA by POC due date.
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was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not evaluate R1 for suitability prior to accepting them. This poses an immediate risk to resident’s health and safety.
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Type A
11/10/2023
Section Cited
CCR87405(h)(1)

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Administrator- Qualifications and Duties. The administrator shall have the responsibility to: Administer the facility in accordance with these regulations and established policy… This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not ensure the
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Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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facility was following regulatory and policy regarding acceptance and retention due to failure to evaluate R1 for suitability prior to accepting them and providing required supervision. This poses an immediate risk to resident’s health and safety.
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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2023 07:04 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/09/2023 at 06:52 PM
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
, 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
87207

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False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This regulation was not met as evidence by: Based on interviews conducted and
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Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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records reviewed the Licensee provided false statements to the Department by stating they had not received R1’s paperwork prior to being admitted and was dropped off at the facility blindly without Licensee consent. Statements were proven to be false. This poses an immediate risk to resident’s safety.
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Type B
11/16/2023
Section Cited
CCR87506(a)

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Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not maintain a complete record for R1
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Per Administrator Assistant the facility will develop a Plan of Action to have current and complete Resident Records. Administrator Assistant to email proof to LPA by POC due date.
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as evidenced by incomplete appraisal and unsigned physician report. This poses a potential risk to resident’s health and safety.
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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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