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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:35:55 PM

Document Has Been Signed on 10/02/2024 01:35 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:
10/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:41 PM
MET WITH:Michelle Song, administrator
Erik Doan, licensee		TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit in order to issue citations for deficiencies observed during a separate unannounced joint visit made for the initial investigation of the allegations contained in complaint reference number #22-AS-20240925103324.

During the visit, LPA observed a cleaning cart in use in the hallway of the facility's memory care unit on the facility's first level. Cleaning cart was observed to contained powdered bleach and bleach in liquid form, both left fully accessible to memory care residents. Additionally, the memory care laundry area's door was found to be unlocked. An uncovered tub of powdered laundry detergent was observed to be present. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D.

A makeshift table made of a wooden platform with a broken glass cover with a sharp edge accessible, balanced on two refrigerators and one cabinet was also observed to be placed in the memory care secure courtyard. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D.

An exit interview was conducted and a copy of this report, attached citations along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 10/02/2024 01:35 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/02/2024 at 01:17 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: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87705(f)(2)

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Per CCR Section 87705(f)(2) on the Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (...) toxic substances such as (...) cleaning supplies and disinfectants". This requirement is not met as evidenced by:
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Licensee will replace the current cleaning carts with lockable carts that enable staff to ensure cleaning products are out of reach of residents in care.
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Based on observation conducted during the visit, cleaning supplies and potential toxic substances were left unattended in the memory care unit. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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Type A
10/03/2024
Section Cited
CCR87303(a)

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Per CCR Section 87303(a): "The facility shall be clean, safe, sanitary and in good repair at all times." This requirement is not met as evidenced by:
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Licensee stated they would proceed to the immediate removal of the dangerous item.
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Based on observation, the presence of a makeshift table balanced on refrigerator, with a broken glass cover constitutes an immediate risk to the health, safety and personal rights of individuals 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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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