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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:59:42 PM

Document Has Been Signed on 12/07/2023 12:59 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: 103DATE:
12/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Joo Eun Ra-Receptionist, Anna Jung-Administrator AssistantTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 11/09/2023. LPA was greeted and granted entry into the facility by Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after.

*Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee submitted a Plan of Action to prevent future elopements and conducted an in-house training and submitted correction timely. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87411(a) pertaining to Personnel Requirements has been cleared. Licensee submitted a Plan of Action to have sufficient personnel at all times and submitted correction timely. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87456(a) pertaining to Evaluation of Suitability for Admissions has been cleared. Licensee submitted a Plan of Action and submitted correction timely. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87405(h)(1) pertaining to Administrator- Qualifications and Duties has been cleared. Licensee submitted correction timely. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87207 pertaining to False Claims has been cleared. Licensee submitted correction timely. Licensee has complied with the POC.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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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: 12/07/2023
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*Deficiency cited under Title 22 Regulation 87506(a) pertaining to Resident Records has been cleared. Licensee submitted a Plan of Action and submitted correction timely. Licensee has complied with the POC.

Licensee has been advised to maintain compliance in all items previously cited.

An exit interview was conducted with ADA Jung and a copy of this was provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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