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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 08/19/2024
Date Signed: 08/19/2024 10:21:04 AM

Document Has Been Signed on 08/19/2024 10:21 AM - 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:		MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 112DATE:
08/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:44 AM
MET WITH:Man ParkTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701. LPA met with Staff #1 (S1) Man Park and Staff #2 (S2) James Lee and explained the reason for today’s inspection. Administrator (AD) Michelle Song was not present during the inspection. Licensee (LE) Erik Doan appeared via telephone.

During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, and requested and reviewed copies of the resident roster, staff roster, and resident files. LPA observed that the two east outside gates from the memory care unit were not alarmed.

During today’s inspection, LPA, S1, and S2 inspected the memory care and tested all exit doors, reviewed the facility’s fire clearance and pre-licensing documents, and observed the following:

The facility’s memory care unit is located on the first floor.

The main delayed egress door is in the center of the memory care unit near the common area and dining room and leads to an elevator and stairs to access the second floor of the facility. Per the facility’s fire clearance and pre-licensing inspection, the main delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the main delayed egress door and observed that it failed to unlock after multiple attempts.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 08/19/2024
NARRATIVE
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The east delayed egress door is the first door on the east side of the memory care unit, at the end of the hallway, and leads to the second east hallway door. Per the facility’s fire clearance and pre-licensing inspection, the east delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the east delayed egress door and observed it to be functioning properly. A few feet further east of the east delayed egress door, in the same hallway and leading to an outside area marked as “Exit” on the facility’s fire clearance, is the second east hallway door. LPA, S1, and S2 tested the second east hallway door and observed that it did not have delayed egress functionality or an alarm, but per the facility’s fire clearance and pre-licensing inspection, the second east hallway door is not required to have delayed egress functionality or an alarm, as the east delayed egress door already serves that function and Room 101 is not a part of the memory care unit.

The west delayed egress door is on the west side of the memory care unit in the common area and dining room and leads to an outside courtyard to the west of the memory care unit. Per the facility’s fire clearance and pre-licensing inspection, the west delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the west delayed egress door and observed that it was readily openable without any delayed egress functionality or alarm being triggered. S1, S2, and LE stated that the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard.

At the north end of the memory care unit’s outside courtyard, there is the north outside gate. LPA, S1, and S2 observed that the north outside gate is kept lock. Per the facility’s fire clearance, this gate is not to be used as an exit in case of an emergency. Per S2, the fire department did not approve of this door’s use as an emergency exit because it leads to stairs going up.

At the south end of the memory care unit’s outside courtyard, there is an outside pathway leading east to the outside of the east side of the memory care unit. At the end of this outside pathway, there is the first east outside gate which is operational and kept unlocked and leads north. LPA, S1, and S2 tested the first east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the first east outside gate did appear to have an alarm mechanism, the alarm did not function.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 08/19/2024
NARRATIVE
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North of the first east outside gate is an outside pathway leading north. This area is marked as “Exit” on the facility’s fire clearance and can also be reached via the second east hallway door. At the north end of the “Exit” area is the second east outside gate which is operational and kept unlocked and leads north to the outside of the facility. LPA, S1, and S2 tested the second east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the second east outside gate did appear to have an alarm mechanism, the alarm did not function.

LE stated they will immediately repair the main delayed egress door and the west delayed egress door. LE stated they understand that the first and second east outside gates cannot be locked. LE stated that, while the west delayed egress door is an essential part of the facility’s delayed egress system, the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard and staff supervision is used to prevent wandering. In light of the risk of residents wandering from the outside courtyard, licensee stated they will install alarms on the first and second east outside gates and will consult with LPA and the local fire department to determine whether installing a delayed egress system on one of the two east outside gates is necessary and allowable and will install one if it is necessary and allowable or take other measures as required to address the risk of residents wandering from the outside courtyard.

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. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report 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: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2024 10:21 AM - It Cannot Be Edited


Created By: Sean Haddad On 08/19/2024 at 10:14 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: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance
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Licensee stated they will immediately repair the main delayed egress door and the west delayed egress door by POC due date and will take all required and allowable measures to address the risk of residents wandering from the outside courtyard.
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 because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate 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: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


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