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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 10/16/2024
Date Signed: 10/16/2024 05:34:30 PM

Document Has Been Signed on 10/16/2024 05:34 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: 129DATE:
10/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:36 PM
MET WITH:Michelle SongTIME VISIT/
INSPECTION COMPLETED:
05:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Administrator Michelle Song and explained the reason for the visit. During the 10-day visit for complaint #22-AS-20241010093603 LPA observed the following which is not directly related to the complaint being investigated. LPA and the Administrator toured the facility. LPA observed the See Something, Say Something Poster (PUB 475) measures 10 inches by 16 1/4 inches. LPA observed resident room 233 where Resident 1 lives did not have a smoke detector. LPA observed wires hanging from the ceiling where the smoke detector goes. The Administrator reported that Resident 1 is moving to room 321 and the staff is in the process of moving Resident 1's belongings. LPA informed the Administrator all resident rooms are required to have a smoke detector. The Administrator verified that the there is no smoke detector in room 233. Room 233 still has Resident 1's clothes and personal items. LPA interviewed Staff 1 and LPA reviewed the facility Guardian roster. Staff 1 is not associated to the facility. LPA informed the Administrator and Staff 1 that they cannot be at the facility until they are associated to the facility. Staff 1 does have a background clearance but is not associated to the facility. LPA observed Staff 1 leave the facility. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Civil penalties being issued for the deficiencies cited; CCR 87203 and CCR 87355(e)(2). An exit interview was conducted and a copy of the report LIC 809, LIC 809D, LIC 421 IM, LIC 421 BG, provided along with appeal rights.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 05:34 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/16/2024 at 03:00 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: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
CCR
87355(e)(2)

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(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(2)Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Licensee agrees to associate Staff 1 to the facility and to submit a statement that they have read and understand the regulation 87355 Criminal Record Clearance. Licensee agrees to forward proof of correction to LPA.
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This requirement was not met as evidenced by, through record review LPA observed Staff 1 has a background clearance but is not associated to the facility. This poses an immediate health and safety and personal rights risk to residents in care.
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Type A
10/17/2024
Section Cited
CCR87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by:
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Licensee agrees to have a smoke detector installed in each resident room.
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LPA observed Resident 1's room, 233 did not have a smoke detector. 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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