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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 03/26/2025
Date Signed: 03/26/2025 09:11:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240624114306
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: 96DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
07:33 AM
MET WITH:Michelle SongTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Facility staff did not obtain timely medical care for resident.
Facility staff did not ensure that resident was administered their medication(s) as prescribed.
Facility staff offered oxygen to resident without a doctor's order.
Facility staff failed to notify responsible party of injury.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.
The investigation into the allegations that facility staff did not obtain timely medical care for resident, facility staff did not ensure that resident was administered their medication(s) as prescribed, facility staff offered oxygen to resident without a doctor's order, and facility staff failed to notify responsible party of injury revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed witnesses and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Physician’s Report dated February 28, 2024, R1’s Primary Care Medical Records, R1’s Home Health Medical Records, a facility communication log entry dated April 7, 2024, R1’s Chapman Global Medical Records, R1’s Chapman Care Center Medical Records, R1’s Garden Grove Hospital Medical Records, R1’s Medication Administration Records for March 2024, and R1’s Medication List dated February 29, 2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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Regarding the allegation that facility staff did not obtain timely medical care for resident: it was alleged that the facility did not obtain timely medical care for R1 after their fall. R1’s responsible party stated that, prior to April 2024, R1 was able to talk, walk, and eat, and that R1 had been seen by their doctor and determined to be in good health. Per R1’s Physician’s Report dated February 28, 2024, R1 had confusion but was able to follow instructions and communicate their needs. Per R1’s Primary Care Medical Records, R1 was referred to home health for physical therapy relating to movement on February 29, 2024, R1 had diagnoses of Dementia, major depressive disorder, abnormalities of gait and mobility, and generalized muscle weakness, and R1 required a walker. Per R1’s Primary Care Medical Records, R1’s doctor examined R1 on March 22, 2024, and noted R1 to be alert to person, place, and time and determined R1’s physical examination to be within normal limits. R1’s Home Health Medical Records revealed that R1 required assistance with most activities of daily living, could not independently make changes in body position, required a walker for walking, and had multiple risk factors for falling, including a prior history of falls within three months. R1’s Home Health Medical Records indicate that physical therapy sessions were conducted at the facility, R1 had good participation in all exercises, was making progress, had a good appetite during the March 28, 2024, and April 4, 2024, sessions, but was noted as having new pain and weakness during the April 11, 2024, session. R1’s physical therapist stated that they had noticed a bruise on R1’s face, were advised by R1 that they had fallen, and reported the fall to the facility.
R1’s responsible party stated that on April 8, 2024, shortly after 12:00PM, they visited R1 at the facility and found that R1 was lying in bed, was unable to open their eyes, had difficulty speaking, had a bruise on their left eyelid, and complained of pain when they were touched. R1’s responsible party was told by Staff #1 (S1) that R1 had fallen while trying to go the bathroom and that R1 was not injured, but S1 did not say when the fall occurred or provide additional details. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024 indicates that at 11:00AM, Staff #2 (S2) reported that R1 was lying on the floor, R1 denied falling, S1 checked R1’s vitals which were normal and noted no bruises or bleeding, R1 refused to go to the hospital, S1 gave R1 Tylenol, R1 went the rest of the day “without any symptoms”, and Staff #3 (S3) was present during this incident as well. Per facility staff, S1 no longer works at the facility and multiple attempts to interview S1 were unsuccessful. S2 remembered seeing R1 on the floor on April 7, 2024, but could not recall any other details from the incident. S2 stated that the last time they saw R1 before the fall was between 8:30AM and 9:00AM. S3 recalled seeing R1 on the floor on April 7, 2024, at 11:00AM, stated that they had last checked on R1 around 10:30AM, and did not recall seeing any injuries on R1.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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Per R1’s responsible party, on April 9, 2024, R1’s family visited R1 and noted R1 was unable to eat solid food, speak, or open their eyes. On April 10, 2024, R1’s responsible party visited R1, was not told anything by staff about R1 having a fall, and noted R1 could not open their eyes or speak and that every movement R1 made was so painful that R1 screamed. On April 11, 2024, R1’s responsible party visited R1 and noted R1 could not talk, had a new bruise on their right cheek, and was unable to walk. On April 12, 2024, R1’s responsible party visited R1 and noted R1 appeared to be getting worse and requested that R1 be taken to a hospital.
Per R1’s Chapman Global Medical Records, R1 was seen in the emergency department on April 12, 2024, with chief complaints of hip and face pain, swelling above the right eye, decreased appetite, and increased pain. Testing revealed a right subdural hematoma (brain bleed) up to 14 millimeters thick, a comminuted (three or more pieces of broken bone) depressed fracture of the right zygomatic arch (cheek bone), but no skull fracture. R1 was determined to need a higher level of care, was admitted for inpatient treatment that same day, and was thereafter discharged to Chapman Care Center on May 1, 2024. Per R1’s Chapman Care Center Medical Records, R1 was admitted for skilled nursing care on May 1, 2024, R1’s diagnoses included traumatic subdural hemorrhage (brain bleed) without loss of consciousness, R1 had hip pain but no hip fracture, and R1 was transferred to Garden Grove Hospital on May 16, 2024, because they needed a higher level of care. Per R1’s Garden Grove Hospital Medical Records, R1 was admitted on May 16, 2024, with a chief complaint of respiratory distress and a history that included subdural hemorrhage (brain bleed), R1 had difficulty breathing, and R1 passed away on May 17, 2024. Based on the information obtained, after R1 fell on April 7, 2024, the facility did not properly report R1’s fall or subsequent change of condition to R1’s doctor and did not have R1 timely medically assessed.
Regarding the allegation that facility staff did not ensure that resident was administered their medication(s) as prescribed: it was alleged that on April 11, 2024, R1’s responsible party visited R1 in the morning, stayed with R1 in their room until 7:30PM, noticed R1 had not received their evening medications, inquired with staff and was told the medications should have been given around 5:00PM, and then observed a medication technician hurriedly give R1 their evening medications. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Per R1’s Medication Administration Records for March 2024, two medications, Atenolol (a blood pressure medication) and Simvastatin (a cholesterol medication), were not given for the last three days of the month, but no reason was documented for withholding these medications. Per a facility communication log entry dated April 7, 2024, S1 administered Tylenol to R1 after a fall on that date.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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R1’s Primary Care Medical Records dated April 18, 2024, do not indicate that these two medications were discontinued or that there were any instructions for withholding these medications and also do not list Tylenol as an ordered medication. R1’s Medication List dated February 29, 2024, also does not list Tylenol as an ordered medication. The information obtained corroborated that facility staff did not administer R1’s medications as prescribed.
Regarding the allegation that facility staff offered oxygen to resident without a doctor's order: it was alleged that on April 8, 2024, R1 was seen with an oxygen tank in their room and S1 stated they had tried to give R1 oxygen because R1 could not breath. R1’s Medication List dated February 29, 2024, and R1’s Primary Care Medical Records do not include orders for oxygen. However, per a facility communication log entry dated April 7, 2024, S1 offered oxygen to R1 and R1 refused the oxygen. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Although R1 refused the oxygen during this particular incident, facility staff still offered R1 a medication for which they did not have a doctor’s order. The information obtained corroborated the allegation. Regarding the allegation that facility staff failed to notify responsible party of injury: it was alleged that on April 8, 2024, R1’s responsible party observed that R1 had sustained an injury at the facility, S1 confirmed that R1 had fallen but was unable to explain how or when R1 had fallen, R1’s responsible party had not been notified of this injury, and S1 stated they did not notify R1’s responsible party of R1’s injury because they did not have the authority to do so. Review of Orange County Regional Office (OCRO) records revealed that the facility did not report this incident or any other incident involving R1 to the OCRO. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024, indicates that R1’s fall occurred at 11:00AM on April 7, 2024, however it is unknown when this document was given to R1’s responsible party and it does not include all required information such as R1’s identifying information, the physician’s name, findings and treatment, and the disposition of the case. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). 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: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2025
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a)… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee stated that they will retrain staff on obtaining medical assessments and care for residents following falls and changes of condition and will submit proof to LPA by POC due date.
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Based on interviews and documents, the licensee did not notify R1’s doctor or obtain a medical assessment after R1’s fall and did not obtain medical care for R1 in response to R1’s change of condition, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.
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Type A
03/27/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by
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The licensee stated that they will retrain staff on ensuring residents receive their medications as prescribed and properly completing the Medication Administration Record and will submit proof to LPA by POC due date.
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Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by not giving them their prescribed medications for multiple days, which poses an immediate health 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2025
Section Cited
CCR
87465(a)(5)(A)
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87465 Incidental Medical and Dental Care. (a) … (5) ... Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
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The licensee stated that they will retrain staff on not giving residents medications that are not on their med lists and submit proof to LPA by POC due date.
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This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by offering R1 oxygen and giving R1 Tylenol which were not prescribed, which poses an immediate health risk to persons in care.
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Type B
04/09/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days … shall include the resident's name, age, sex and date of admission; date and nature of event…
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Licensee stated that they will create a plan to ensure incidents are properly reported and will submit proof to LPA by POC due date.
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This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide a written report of R1’s fall to the OCRO or R1’s responsible party, which poses a potential health 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240624114306

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: 96DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
07:33 AM
MET WITH:Michelle SongTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Questionable Death.
Facility does not have enough staff to meet residents' needs.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.

The investigation into the allegations of questionable death and that facility does not have enough staff to meet residents' needs revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Primary Care Medical Records, a facility communication log entry dated April 7, 2024, R1’s Chapman Global Medical Records, R1’s Chapman Care Center Medical Records, R1’s Garden Grove Hospital Medical Records, R1’s Certificate of Death, and the facility’s April 2024 staff schedule.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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Regarding the allegation of questionable death: it was alleged that lack of care and supervision resulted in R1 passing away. R1’s responsible party stated that, prior to April 2024, R1 was able to talk, walk, and eat, and that R1’s doctor had seen R1 on March 22, 2024, and determined R1’s physical examination to be within normal limits. R1’s responsible party stated that on April 8, 2024, shortly after 12:00PM, they visited R1 at the facility and found that R1 was lying in bed, was unable to open their eyes, had difficulty speaking, had a bruise on their left eyelid, and complained of pain when they were touched. R1’s responsible party was told by Staff #1 (S1) that R1 had fallen while trying to go the bathroom and that R1 was not injured, but S1 did not say when the fall occurred or provide additional details. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024 indicates that at 11:00AM, Staff #2 (S2) reported that R1 was lying on the floor, R1 denied falling, S1 checked R1’s vitals which were normal and noted no bruises or bleeding, R1 refused to go to the hospital, S1 gave R1 Tylenol, R1 went the rest of the day “without any symptoms”, and Staff #3 (S3) was present during this incident as well. Per facility staff, S1 no longer works at the facility and multiple attempts to interview S1 were unsuccessful. S2 remembered seeing R1 on the floor on April 7, 2024, but could not recall any other details from the incident. S2 stated that the last time they saw R1 before the fall was between 8:30AM and 9:00AM. S3 recalled seeing R1 on the floor on April 7, 2024, at 11:00AM, stated that they had last checked on R1 around 10:30AM, and did not recall seeing any injuries on R1. Per R1’s responsible party, on April 9, 2024, R1’s family visited R1 and noted R1 was unable to eat solid food, speak, or open their eyes. On April 10, 2024, R1’s responsible party visited R1, was not told anything by staff about R1 having a fall, and noted R1 could not open their eyes or speak and that every movement R1 made was so painful that R1 screamed. On April 11, 2024, R1’s responsible party visited R1 and noted R1 could not talk, had a new bruise on their right cheek, and was unable to walk. On April 12, 2024, R1’s responsible party visited R1 and noted R1 appeared to be getting worse and requested that R1 be taken to a hospital.

Per R1’s Chapman Global Medical Records, R1 was seen in the emergency department on April 12, 2024, with chief complaints of hip and face pain, swelling above the right eye, decreased appetite, and increased pain. Testing revealed a right subdural hematoma (brain bleed) up to 14 millimeters thick, a comminuted (three or more pieces of broken bone) depressed fracture of the right zygomatic arch (cheek bone), but no skull fracture. R1 was determined to need a higher level of care, was admitted for inpatient treatment that same day, and was thereafter discharged to Chapman Care Center on May 1, 2024.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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Per R1’s Chapman Care Center Medical Records, R1 was admitted for skilled nursing care on May 1, 2024, R1’s diagnoses included traumatic subdural hemorrhage (brain bleed) without loss of consciousness, R1 had hip pain but no hip fracture, and R1 was transferred to Garden Grove Hospital on May 16, 2024, because they needed a higher level of care. Per R1’s Garden Grove Hospital Medical Records, R1 was admitted on May 16, 2024, with a chief complaint of respiratory distress and a history that included subdural hemorrhage (brain bleed), R1 had difficulty breathing, and R1 passed away on May 17, 2024. R1’s Certificate of Death identifies the causes of death as cardiopulmonary arrest (within minutes), acute respiratory failure (within days), septic shock (within days), and pneumonia (within days) with no other contributing factors noted. Based on the information obtained, R1 was in stable condition and making improvements prior to their fall and R1’s fall triggered a sudden decline in R1’s condition which led to R1’s hospitalization. However, R1 received inpatient and skilled nursing care for more than a month before they passed away.
Regarding the allegation that the facility does not have enough staff to meet residents' needs: it was alleged that on April 10, 2024, R1’s responsible party activated R1’s signal system for assistance, but no care staff came, and R1 inquired with the receptionist and was advised to just wait because there were no care staff available to help. Per interviews with three staff who worked at the facility between April 8, 2024, and April 12, 2024, status checks were conducted on R1 at least every two or three hours. Interviews with two residents revealed that staff are responsive to calls on the signal system and status checks are conducted on residents throughout the day. The staff in charge of overseeing the facility’s signal system reported that calls are usually answered immediately unless the staff are busy providing care to another resident and the longest wait is usually around five minutes. Per the facility’s April 2024 staff schedule, there are nine care staff scheduled for the morning shift, six care staff scheduled for the afternoon shift, and three care staff scheduled for the overnight shift, in addition to the medication technician, receptionist, and activity coordinator. One staff interviewed reported that there are two caregivers assigned to the 30 residents in the memory care during the day shifts. While response times for the signal system may fluctuate, the information obtained regarding whether there are enough staff to meet residents’ needs is conflicting.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240624114306

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: 96DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
07:33 AM
MET WITH:Michelle SongTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Facility staff are not adequately trained.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.

The investigation into the allegation that facility staff are not adequately trained revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, and Staff #1’s (S1) Staff File.

Regarding the allegation that facility staff are not adequately trained: it was alleged that on April 8, 2024, R1’s responsible party observed that R1 had sustained an injury at the facility, S1 confirmed that R1 had fallen but was unable to explain how or when R1 had fallen, and S1 had not notified R1’s responsible party of R1’s injury because S1 was not properly trained.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 22-AS-20240624114306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 03/26/2025
NARRATIVE
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Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Per S1’s Staff File, S1’s medication training and first aid training were up to date. On April 17, 2024, LPA reviewed 10 staff files, including the file of S1, and confirmed they had all completed their required training, including training on reporting requirements. Interviews with two residents did not reveal issues relating to staff training. The information obtained did not corroborate the allegation and showed that facility staff had completed all required training.

The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 11 of 11