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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:04:29 PM

Document Has Been Signed on 09/12/2024 05:04 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/
DIRECTOR:		MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 120DATE:
09/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:31 PM
MET WITH:Erik Doan, Licensee
Michelle Song, Administrator		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a plan of corrections visit following up on the type A deficiency citation issued on August 18, 2024 after two out of three delayed egress exits in the memory care unit were observed to be inoperational.

LPA accompanied by administrator toured the memory care unit and observed that no repairs had been conducted on the exits at this time. Delayed egress doors are therefore still not in operation.

A type A deficency is cited on this day on an attached form LIC809-D.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 09/12/2024 05:04 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 09/12/2024 at 04:55 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
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 states that a pricing proposal and scheduled appointment will be made before end of business day. This is a repeat/continuation of the initial deficiency cited on August 18, 2024. No additional immediate civil penalty cited at this time.
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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.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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