306090049-4-15-2025-22-AS-LMOA-DG9366-20250430175750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:05:04 PM

Unsubstantiated

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
07/18/2023 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230718165749

FACILITY NAME:	GRACE RETIREMENT VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	HYO(MONICA)SOOK KIM		FACILITY TYPE:	740
ADDRESS:	1100 E. WHITTIER BLVD.		TELEPHONE:	(562) 694-6515
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 99	DATE:	04/15/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Michelle Song		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not obtain timely medical treatment after resident sustained an unwitnessed fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Tirre was greeted and granted entry into the facility by Administrator Michelle Song and explained the reason for the visit.

During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Los Angeles Community Hospital Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following:
Resident 1 (R1) was admitted to the facility on May 26, 2023. Per physician report dated June 07, 2023, R1 has a primary diagnosis of hypertension with no cognitive impairments. R1 is further listed as having a diagnosis of osteoporosis and able to communicate needs.
On July 17, 2023, R1 was admitted to Los Angeles Community Hospital at 9:47 PM, after informing facility staff they had sustained an unwitnessed fall and began complaining of hip pain.

CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230718165749

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: 04/15/2025

NARRATIVE

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At the time of being admitted, hospital records report R1 was unable to move or walk. Upon being admitted, R1 was diagnosed with a pelvic fracture.

Based on interview, a facility staff (S1) stated on 7/17/23, R1 informed S1 that they had fallen in their bedroom after lunch but denied experiencing any pain or discomfort. S1 did not observe bruises or swelling on R1; however, R1 appeared to be in pain at the hip prompting S1 to persuade R1 to go to the hospital. S1 did not contact 911, as the situation was not considered an emergency or life-threatening. Instead, S1 called area hospitals, and Los Angeles Community Hospital was the only nearby hospital with medical transport vehicles available. An ambulance arrived and transported R1 to the hospital. R1’s Power of Attorney (POA) was notified prior to the transport.

When interviewed, R1 could not recall how they fell but stated they felt safe at the facility. R1’s Power of Attorney (POA) reported last seeing R1 on July 15, 2023, at which time R1 appeared to ambulate fine and did not complain of any pain or discomfort. Per facility needs and assessment plan dated May 26, 2023, R1 uses a walker when ambulatory and has no limitations when transferring to bed.

Although R1 sustained an unwitnessed fall and staff did not immediately call 9-1-1, R1 was able to communicate their pain level to staff and did not present in dire need to be medically evaluated. Based on R1’s assessment, R1 was alert and able to accurately communicate their needs. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator Song, and a copy of this report and confidential names list was left at the facility.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC9099 (FAS) - (06/04)

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