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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:06:31 PM

Document Has Been Signed on 11/06/2024 12:06 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
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: 130DATE:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:35 AM
MET WITH:Michelle SongTIME VISIT/
INSPECTION COMPLETED:
11:00 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-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, and staff schedule.
Per the facility’s staff schedule, Staff #1 (S1) Alma Cervantes works at the facility regularly. Per admission from Licensee (LE) Erik Doan, S1 has worked at the facility for more than five days. LPA determined using the Licensing Information System that S1 is not background cleared and has been working at the facility since May 12, 2023, per their staff file.

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 LIC421BG. 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: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 12:06 PM - It Cannot Be Edited


Created By: Sean Haddad On 11/06/2024 at 12:00 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (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: (1) Obtain a California clearance… This requirement was not met as evidenced by:
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Licensee stated that they will have S1 background cleared and submit proof to LPA by POC due date.
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Based on interviews and documents, the licensee did not S1 was background cleared prior to working at the facility for at least 5 days, which poses an immediate safety risk to persons in case. 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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