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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 12/20/2023
Date Signed: 12/20/2023 11:34:56 AM

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
05/31/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230531150652
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: 105DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Joo Eun Ra-Receptionist, Anna Jung-Administrator AssistantTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
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 Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after.

Resident 1 (R1) was admitted to the facility on May 03, 2023. R1’s Physician report dated May 06, 2023, lists R1 as having a diagnosis of Hypertension and Type II Diabetes. R1 is noted as not being able to communicate needs but able to leave the facility unassisted. Four days later R1’s physician report was updated on May 10, 2023, as being able to communicate their needs with a note that said R1 wanted to handle their needs by themselves. During the investigation the Department spoke with the physician listed as completing the physician reports. A true signature was presented by the physician and their attorney. The Department determined the signature presented by the physician and the signature observed on the reports CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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 3
Control Number 22-AS-20230531150652
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: 12/20/2023
NARRATIVE
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did not match.

On May 31, 2023, R1 was hospitalized after an unwitnessed fall. R1 was hospitalized at St. Jude Medical Center and was admitted for severe sepsis. At the time of being admitted, hospital staff observed R1 with multiple burns and skin tears across the upper and lower body. Staff interviewed denied observing burns and stated the burns were carpet burns. Pictures taken by hospital staff depict skin tears and burns resulting in blisters over R1’s extremities including arms, fingers and legs. When shown the pictures, Staff 1 (S1) advised investigators carpet burns don’t blister. Hospital records diagnose R1 with a history of dementia but are unclear where/how they came to know R1 had a history of dementia. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. EMT personnel interviewed recalled speaking with their partner and saying the arm injury observed on R1 was “definitely not a skin tear” as reported by staff. The responder recalled seeing the resident’s arm as having some sort of burn but could not recall if it was or was not wrapped upon arrival. Although it remains unclear exactly how the resident sustained the injuries, it is clear the injuries sustained occurred while in care at the facility and contributed to the R1’s hospitalization.

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(f)

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

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230531150652
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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision…This requirement was not met as evidence by: Licensee failed to ensure R1 was receiving care and supervision which resulted in R1 sustaining a burn from an unknown cause while in the care of the
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Per Administrator Assistant facility will conduct an in-house training with all staff. Administrator Assistant to email proof to LPA by POC due date.
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facility as evidence by interviews conducted and hospital records reviewed. 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3