306090049-4-22-2025-22-AS-AJLO-DG7TGH-20250429144310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:17:11 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
12/23/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241223122921

FACILITY NAME:	GRACE RETIREMENT VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	MICHELLE SONG		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:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Michelle Song, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Memory Care residents are not being showered.
Resident has an infection due to neglect by staff.
Staff are not assisting residents who needs assistance with feeding.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Michelle Song, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted.
It is alleged that memory care residents are not being showered. Record review reflects that facility uses a schedule as well as a shower body check from that caregivers use when showering the residents. The shower schedule reflects two shower schedules for morning and evening showers. Schedule and log reflect the residents in memory care that received showers and the time. Interview with 6 of 6 residents

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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-20241223122921

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: 04/22/2025

NARRATIVE

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stated that they get help with showers, and they have never had an issue with getting a shower.
It is alleged that resident has an infection due to neglect by staff. Interview with resident (R1) states that they have a nurse that comes out every 8 days to check their catheter and overall health, that same nurse comes once a month to change out the catheter. R1 states they have never had an issue as the nurse is consistent with her visits. Facility staff help with everything they need and are very friendly and nice to them. They have always gotten me the help that they have needed. R1 indicated that they get assistance with showers, repositioning, food delivery, but he doesn’t need help with eating. R1 doesn’t recall every having an infection while being at the facility. Interview with 2 of 2 staff that assist R1 states that they help R1 with showers, bringing food trays and anything else that R1 may need. They don’t recall R1 having an infection every while here at the facility.

It is alleged that staff are not assisting residents who need assistance with feeding. On January 2, 2025, LPA Mason conducted a complaint visit and observed resident in various dining rooms at the facility eating their own meals not needing assistance. Staff was delivering food trays and on the third floor observed two residents in the dining room receiving feeding support from staff during lunch. On todays visit LPA Martinez observed various residents in all dining rooms receiving assistance with feeding. LPA observed staff spoon feeding residents and/or guiding resident with feeding. LPA Martinez made the observation in the breakfast and lunch times. Interview with 3 of 3 staff stated that caregivers help those residents that need assistance with feeding by either doing spoon feeding and/or giving stand by assist with feeding. Trays are delivered to residents’ room and if resident needs assistance with feeding another caregiver comes to provide that assistance. Interview with 6 of 6 residents stated that they have been assisted or have observed that staff help residents with feeding.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Administrator and a copy was furnished to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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