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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 10/16/2024
Date Signed: 10/16/2024 05:29:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241010093603
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 129DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Michelle SongTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility staff served expired food to residents.
Facility does not have sufficient night staffing to meet residents needs.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Michelle Song and explained the reason for the visit. LPA and the Administrator toured the facility including the kitchen. The investigation into the allegation, facility staff served expired food to residents revealed the following. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed the refrigerators and freezers are kept at the required temperatures. LPA inspected the stored food supplies. LPA observed 49 boxes of cereal stored in the kitchen are expired. LPA verified with the Administrator who agreed 49 boxes of cereal are expired. The preponderance of evidence standard has been met, therefore the allegation is substantiated.

The investigation into the allegation facility does not have sufficient night staff to meet residents needs revealed the following.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20241010093603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 10/16/2024
NARRATIVE
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LPA interviewed the Administrator and staff. LPA reviewed facility documents and records. Facility has 3 stories/levels and a total 170 rooms. The memory care unit has 29 rooms is on the first level and has a secured perimeter. According to the staff schedule there are only two staff members for the whole facility from 10:30 pm until 6:00 am. The facility Administrator reported that there are 3 staff members but it is from 11:00pm until 7:30 am but it is not listed on the schedule. The Administrator reported that the staff members who start at 10:30pm are constantly checking the residents throughout the facility. The facility has multiple levels and wings and is required to have a signal system. Each room has a call button and it goes to a central panel at the front lobby desk. LPA tested the signal system and it is operational. According to CCR 87415 the facility is required to have, 87415(a)(3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes. CCR 87415 (a)(5) In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. Based on CCR 87415, three people shall be at the facility from 10:00 pm to 6:00 am, one person on call on the premises, one on duty awake on the premises and one person shall be located to enable immediate response to the signal system. LPA informed the Administrator that even if the schedule reflected the 3 staff members present from 11:00 pm until 7:30 am the regulatory requirement is not being met because 3 staff members must be present from 10:00 pm to 6:00 am. The preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20241010093603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
CCR
87415(a)(5)
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In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake.
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Licensee agrees to schedule a minimum of 3 staff members between the hours of 10:00 pm to 6:00 am everyday. Licensee to forward proof to LPA.
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This requirement is not being met as evidenced by record review and interviews verified the facility does not have a staff person monitoring the signal system to provide immediate response. This poses an immediate health, safety and personal rights risk to residents in care.
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Type A
10/17/2024
Section Cited
CCR
87555(b)(8)
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All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Licensee agrees to discard all expired food. Licensee agrees to train staff on CCR 87555 General Food Service Requirements and to submit proof of training to LPA.
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This requirement is not being met as evidenced by, LPA observed 49 boxes of cereal stored in the kitchen that have expired. This poses an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241010093603

FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 129DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Michelle SongTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Residents are left in soiled diapers for a long period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Michelle Song and explained the reason for the visit. LPA toured the facility with the Administrator. LPA interviewed 6 staff and 6 residents. LPA attempted to interview 5 residents in memory care but none of the residents responded to the LPA. The investigation into the allegation revealed the following. It was alleged that residents were not being assisted with incontinence needs and being left for extended periods of time without assistance. No other details were provided. 6 out of 6 staff members reporting helping residents with all their needs within 15 minutes of assistance being requested. 6 out of 6 residents interviewed reported being helped with 5 to 15 minutes of asking for assistance. No evidence was gathered to corroborate the allegation. Based on the evidence gathered the allegation is unsubstantiated, meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4