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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:48:32 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
10/04/2023 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231004105837
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 99DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Michelle SongTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident developed a stage 3 pressure injury while in care due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jenifer Tirre met with Administrator Michelle Song for the purpose of delivering findings for the above allegations.
The investigation consisted of the following: On October 5, 2023, the department toured the facility, obtained records, interviewed staff and witnesses.

Based on records review, R1 was admitted to the facility on May 26, 2023. R1 is ambulatory and uses a walker, and no history of skin condition or breakdown according to physician’s report dated August 23, 2023. R1’s appraisal/needs and services plan dated August 23, 2023, indicates R1 uses a walker to ambulate, no limitation when transferring to bed, no disorientation, and occasionally incontinent.
The department interviewed four staff (S1, S2, S3, S4). Medication technician (S1) stated caregivers reported to S4, a Licensed Vocational Nurse (LVN) that R1 has a sore on the back on September 15, 2023. Three staff (S1, S2, S3) stated they observed redness, a rash, or a small “red spot” at R1’s coccyx area that was treated with some type of ointment by the facility LVN (S4). CONTINUED ON 9099C
Substantiated
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)
Page: 1 of 5
Control Number 22-AS-20231004105837
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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S3 stated they assisted R1 with bathing, clothing, diaper changes, feeding and checked R1 every two to three hours. S3 denied there was a care log to keep track of the care and services provided to R1. During this investigation, the department made several attempts (dated January 12, 2024, January 17, 2024, January 18, 2024 & January 22, 2024) to reach S4 but was unsuccessful in reaching S4. All three staff members (S1, S2, S3) confirmed that S4 no longer works for the facility. All three staff denied R1 had home health services while in care at the facility.

The department conducted interviews with five witnesses. One witness (W1) revealed on September 17, 2023, W1 observed R1’s buttocks was red and had black dark spots. Other witnesses (W2 and W3) denied being aware of R1’s pressure injury while in care at the facility.

On September 19, 2023, S1 stated R1’s vital signs were checked and found that R1 was not in good condition, 911 was called and R1 was taken to Providence St. Jude Medical Center. R1 was admitted to the hospital for multiple medical conditions and hospital staff discovered the pressure injury on R1. Per review of hospital records and photos, it was revealed that R1 had multi-medical problems including an unstageable coccygeal decubitus ulcer.

That was confirmed by a Medical Consultant II of the Division of Medi-Cal Fraud and Elder Abuse, Office of the Attorney General, Department of Justice, who specializes in Elder Abuse who reviewed R1’s medical records.

On September 22, 2023, R1 was admitted to hospice at Providence St. Jude Medical Center. R1 deceased at the hospital on September 23, 2023 due to cardiopulmonary arrest, sepsis, urinary tract infection and metastatic ovarian cancer per death certificate dated September 28, 2023. It was revealed that R1’s cause of death was unrelated to pressure injury.

Based on observations, interviews and records reviewed, the preponderance of evidence has been met, the allegation, “Resident developed a stage 3 pressure injury while in care due to neglect” is SUBSTANTIATED.

An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An Immediate Civil Penalty is being assessed.

An exit interview was conducted with Administrator Song, and a copy of this report, 9099-D Page, Copy of Civil Penalty Assessment Form and appeal rights was provided.

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)
Page: 2 of 5
Control Number 22-AS-20231004105837
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: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2025
Section Cited
CCR
87615(a)(1)
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87615 (a) Prohibited health conditions. Persons who require health services for or have a health condition including, but not limited to those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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The administrator agreed to ensure all residents with prohibited conditions are not admitted or retained in the facility. The administrator shall conduct an in-service training on pressure injury prevention to all direct care staff.
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Based on observations, interviews, and record review, the licensee retained R1 who had prohibited health condition of unstageable pressure injury while in care at the facility. The licensee failed to seek a higher level of care for R1. This poses an immediate health, safety and/or personal rights risk to residents in care.
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 The administrator shall self-certify understanding and compliance to the section 87615(a)(1). POC shall be submitted to jenifer.tirre@dss.ca.gov by the POC due date.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/04/2023 and conducted by Evaluator Jenifer Tirre
COMPLAINT CONTROL NUMBER: 22-AS-20231004105837

FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility lacks staffing to meet resident's needs
INVESTIGATION FINDINGS:
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Licensing Programming Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation completed by 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 investigation, the Department interviewed staff and witnesses as well as made visual observations. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation.

Based on staff interviews conducted, four staff stated they observed R1 to have a red spot or red rash on R1’s backside above buttocks area. Staff interviews confirmed that staff were providing care checks on R1 every two to three hours. Staff interviews confirmed R1 was being assisted with diaper changes, bathing, clothing and meals. Staff did not observe any open wounds or pressure injuries on R1. Staff interviews state that facility has two Caregivers, one LVN Nurse, one Medication Technician and two House Keepers per shift.
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)
Page: 4 of 5
Control Number 22-AS-20231004105837
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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During visit on 10/5/2023, LPA Tirre observed 13 staff members present and assisting residents with meals and activities of daily living. LPA Tirre did not observe any health and safety risks of residents in care during investigation.

Based on staff interviews and observations the allegation facility lacks staffing to meet resident’s needs is deemed UNSUBSTANTIATED. Based on the information gathered through interviews and observations, there was not a preponderance of evidence to prove or disprove that the Facility lacks staffing to meet residents needs.



An exit interview was conducted with Administrator Michelle Song and a copy of this report was provided to 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)
Page: 5 of 5