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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:00:33 PM

Document Has Been Signed on 04/17/2024 04:00 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR/
DIRECTOR:		CRYSEL SANTOSFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 110DATE:
04/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Erik DoanTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on March 27, 2024. LPA met with Administrator (AD) Erik Doan and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility, reviewed documents, and observed the following:

Type B Violation cited under Health & Safety Code (HSC) section 1569.695(c) pertaining to fire drills has been CLEARED. LPA reviewed records for a fire drill conducted on April 1, 2024.

Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87156(a) pertaining to licensing fees has not been cleared. The plan of correction due date has not yet passed and AD stated they will mail a check and send proof to LPA.

Technical Violation issued under CCR section 87412(a) pertaining to personnel records has been addressed. The staff files are present at the facility. LPA reviewed 10 staff files and LPA and AD observed the following: the files of Staff #1 (S1) and Staff #2 (S2), who are medication technicians, do not contain evidence of the required medication technician training; AD’s administrator certificate is expired and the licensee has not yet designated an administrator with an active certificate.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report, clear letters for all citations cleared during this inspection, and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 04:00 PM - It Cannot Be Edited


Created By: Sean Haddad On 04/17/2024 at 03:41 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: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
HSC
1569.69(a)(1)

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§ 1569.69(a) … (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training... This requirement was not met as evidenced by:
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Licensee stated they will have S1 and S2 complete the required medication technician or properly document the training they already received and submit proof to LPA by POC due date.
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Based on documents, the licensee did not ensure S1 and S2 had documented medication technician training, which poses a potential health risk to persons in care.
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Type B
05/15/2024
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by:
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Licensee stated they will submit the necessary documents to designate a qualified administrator to LPA by POC due date.
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Based on documents, the licensee did not ensure an administrator with an active administrator’s certificate was properly designated, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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