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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 12/20/2023
Date Signed: 12/20/2023 12:18:00 PM

Document Has Been Signed on 12/20/2023 12:18 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: 105DATE:
12/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Anna Jung-Administrator AssistantTIME COMPLETED:
12:24 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 Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency.

On August 24, 2023, during an investigatory follow up visit, Department staff made an unannounced visit to the facility and requested to speak to the Med Tech on duty after being informed Administrator Erik Doan and Licensed Vocational Nurse (LVN) Grace Park were not present. After waiting 15 minutes with no response, Department staff texted Administrator Erik Doan requesting for a status update. After an additional 15 minutes Doan responded that he would return to the facility once done with his meeting and that no one would be interviewed until he was present on site.

It was discovered during the investigation process Resident 1 (R1) had left the property on May 21, 2023, unbeknown to the staff. R1 was disoriented and appearing ill out in on the public street shortly after 2:00 AM and was transported to the hospital. It was not until they were admitted to the hospital that Grace Retirement Village was notified of their whereabouts.

On May 31, 2023, Resident 1 (R1) was hospitalized following an unwitnessed fall. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff.

The following is being cited per Title 22 Division 6 of the California Code of Regulations.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/20/2023 12:18 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 12/20/2023 at 10:50 AM
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: 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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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 evidenced by: On May 21, 2023, R1 eloped from the facility and was transported to the hospital unbeknownst to the facility
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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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This poses an immediate risk to resident’s health and safety.
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Type B
12/27/2023
Section Cited
CCR87405(a)

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Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section…
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Licensee to update Designation of Facility Responsibility (LIC308). Licensee to email updated LIC308 to LPA by POC due date.
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This regulation was not met as evidenced by: Licensee failed to have a qualified designated substitute when Administrator was not in the facility on 8/24/23 as evidenced by Department staff observations and comments made by Administrator. This poses a potential risk to residents health and safety while 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/20/2023 12:18 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 12/20/2023 at 11:04 AM
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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited
CCR
87755(b)

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Inspection Authority of the Licensing Agency. The licensee shall ensure that provisions are made for private interviews with any resident or any staff member... This regulation was not met as evidenced by: Licensee failed to ensure provisions were made for private interviews with staff on 8/24/23 as evidenced
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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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by Administrator’s statements. This poses a potential risk to residents’ personal rights and safety while in care.
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Type B
12/27/2023
Section Cited
CCR87469(c)(1)

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Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel… This regulation was not met as evidenced by:
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Per Administrator Assistant the facility will develop a Plan of Action to ensure resident records are available to emergency personnel
upon request. Administrator Assistant to email proof to LPA by POC due date.
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Licensee failed to ensure records were made available to emergency personnel as evidenced by records being locked inaccessible to staff. This poses a potential risk to resident’s health and safety while 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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