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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:07:19 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
04/23/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240423112858
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:
04/22/2025
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Michelle Song-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Excluded person is operating the facility
Facility is not properly screening residents for Tuberculosis
Facility is not allowing residents to select their own medical providers
Facility is not ensuring residents’ medical needs are met
Administrator is not on the premises a sufficient number of hours to adequately manage the facility
Facility falsified records
Facility staff left residents unsupervised
Facility staff are not providing medications as prescribed
Facility staff are violating residents' personal rights
Facility has insufficient food supplies
Residents are not receiving treatment for scabies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 23, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Michelle Song. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that excluded person is operating the facility. Regarding the allegation the following was revealed: During the course of the interviews one of fourteenth individuals interviewed confirmed the allegations. During the course of the investigation LPA reviewed documents including the Licensing Information System (LIS) Facility Personnel Report Summary dated May 02, 2024. During the subsequent visit on April 11, 2025, LPA reviewed the Guardian Employee Roster dated April 10, 2025. Per LIS Facility Personnel Report Summary and Guardian Employee Roster, Staff 1 (S1) is not associated to the facility. During the course of the interviews with residents, Resident 1 (R1) reported that she does not know if an excluded person is operating the facility.
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 1 of 8
Control Number 22-AS-20240423112858
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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During the course of the interviews with staff, S2 reported that S1 used to work when she started but no more. Per S3 an excluded person is not operating the facility and stated that she does not know S1.

Regarding the allegation that facility is not properly screening residents for Tuberculosis, the following was revealed: During the course of the interviews with staff, S3 reported that she believes that residents get screened properly for Tuberculosis. During the course of the interviews with residents, R1 reported that residents get screened for Tuberculosis. During the investigation LPA reviewed documents including the Physician Reports (LIC602s) for R1-R5. Per Physician Report dated September 16, 2024, R1 tested negative for Tuberculosis. Per Physician Report dated April 10, 2024, R2 tested negative for Tuberculosis. Per Physician Report dated February 06, 2025, R3 tested negative for Tuberculosis. Per Physician Report dated unknown, R4 tested negative for Tuberculosis. Per Physician Report dated January 14, 2025, R5 tested negative for Tuberculosis.

Regarding the allegation that facility is not allowing residents to select their own medical providers, the following was revealed: During the course of the interviews with residents, R1 reported that residents are allowed to select their preferred medical provider. During the course of the interviews with staff, S2 reported that residents can choose their own Doctor. Per S4 the residents have options when it comes to selecting their medical provider. Per S5 the residents choose their own medical provider. LPA reviewed documents including the Grace Retirement Village Admission Agreement. Per Admission Agreement under Resident Participation in Decision Making it states as a resident, you, or your representative, or both, are entitled and encouraged to participate in decision-making regarding your care and services. Per Health and Safety Code section 1569.80(a) it states a resident of a residential care facility for the elderly, or the resident’s representative, or both, shall have the right to participate in decision-making regarding the care and services to be provided to the resident.

Regarding the allegation that facility is not ensuring residents’ medical needs are met, the following was revealed: During the course of the interviews with residents, R1 reported that her medical needs are being met. During the course of the interviews with staff, S2 reported that the residents’ needs are being met and stated that the residents get transported to their medical appointments via medical transportation vans. S3 reported that the residents' medical needs are being met and stated that the Nurses always come to check on the residents. S4 stated that the residents’ medical needs are being met. Per S5 the facility is meeting the residents' medical needs.

CONTINUED ON LIC9099-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 2 of 8
Control Number 22-AS-20240423112858
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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Regarding the allegation that Administrator is not on the premises a sufficient number of hours to adequately manage the facility, the following was revealed: During the course of the investigation LPA reviewed documents including the Personnel Report (LIC500) dated April 01, 2024. Per Personnel Report AD is schedule to work Monday through Friday from 9:00 a.m. to 5:00 p.m. LPA also reviewed the Personnel Report dated April 04, 2025. Per Personnel Report AD Michelle Song is scheduled to work Monday through Friday from 9:00 a.m. to 5:00 p.m. During the course of the interviews with residents, R1 reported that the AD is always in and out of the facility and stated that the AD is helpful. During the course of the interviews with staff, S2 reported that the AD is at the facility at 8:00 a.m. and is still here after she is off at 3:30 p.m. Per S4 the AD is at the facility from 8:00 a.m. to 6:00 p.m. Per S5 the AD is at the facility every day for a couple of hours.

Regarding the allegation that facility falsified records, the following was revealed: During the course of the interviews one of fourteenth individuals interviewed confirmed the allegation. During the course of the interviews with residents, R1 reported that she does not know if staff falsify records. During the course of the interviews with staff, S2 reported that staff have never falsified records. Per S3 she is not aware if the staff have falsified records. S5 reported that staff have not falsified facility records.

Regarding the allegation that facility staff left residents unsupervised, the following was revealed: During the course of the interviews with residents, R1 reported that staff never leave the residents unsupervised. During the course of the interviews with staff, S2 reported that staff have never left the residents unsupervised. Per S3 she has never seen residents being left unattended. S4 stated that staff never leave the residents unsupervised. Per S5 caregivers check on the residents every two to three hours. During the two subsequent visits LPA observed one Medication Technician and six caregivers on duty for 99 residents in care.

Regarding the allegation that facility staff are not providing medications as prescribed, the following was revealed: During the course of the investigation LPA reviewed documents including the Medication Administrator Record (MAR) dated April 2025 for R1-R5. Per MAR R1-R5 are getting their medications as prescribed. During the course of the interviews with residents, R1 reported that she gets her medications as prescribed. During the course of the interviews with staff, S4 reported that staff are giving the medications as prescribed. Per S5 staff give the medications as prescribed by the Doctor.

CONTINUED ON LIC9099-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 3 of 8
Control Number 22-AS-20240423112858
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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Regarding the allegation that facility staff are violating residents' personal rights, the following was revealed: During the course of the investigation LPA reviewed documents including the Resident Personal Rights in-service training dated November 07, 2024. LPA also reviewed the Health and Safety of Residents in-service training dated January 15, 2025. During the course of the interviews with residents, R1 reported that staff respect the residents' personal rights and reported that staff are nice. During the course of the interviews with staff, S2 reported that staff are not violating the residents' rights and reported that staff do their best. Per S3 staff are very respectful and always respect the residents’ personal rights. S4 stated that staff are very educated and reported that staff do not violate the residents' personal rights.

Regarding the allegation that facility has insufficient food supplies, the following was revealed: During the subsequent visit on April 11, 2025, LPA tour the kitchen and observed the following: onions, oranges, lemons, carrots, lettuce, eggs, broccoli, rice, frozen meats and unexpired canned food. During the subsequent visit on April 22, 2025, LPA tour the facility and observed the following: LPA observed staff cooking squash with shredded chicken for lunch. LPA observed unexpired canned foods such as green beans, mixed vegetables, diced tomatoes, white chicken, salmon, peanut butter, beans and mashed potatoes. LPA also observed bread, bananas, potatoes and carrots. During the investigation LPA reviewed documents including the Grace Retirement Village weekly menu dated March 20, 2025. Per weekly menu the residents get a different meal for breakfast, lunch and dinner. Per weekly menu under alternatives, it states: ham/turkey sandwich, egg salad sandwich, chef salad, omelette, peanut butter and jelly or hot dog. During the course of the interviews with residents, R1 reported that the food is not that great and reported that she gets enough food and can substitute an item that she does not like. During the course of the interviews with staff, S2 reported that the facility has enough food and stated that if a resident wants more that they can ask for seconds. Per S3 if a resident asks for a substitution the kitchen staff will provide it. S4 stated that the facility has enough food and reported that the residents have not complained about the food.

Regarding the allegation that Residents are not receiving treatment for scabies, the following was revealed: During the course of the interviews with residents, R1 reported that she has not had scabies and reported that she does not know if there were scabies. During the course of the interviews with staff, S3 reported that she has never seen scabies and stated that management has never informed staff about scabies. S3 stated that she has been working here for five years and reported that she has never had an infection. S3 reported that if there were scabies that she would be infected since she provides showers. Per S4 no resident has had scabies.

CONTINUED ON LIC9099-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 4 of 8
Control Number 22-AS-20240423112858
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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During the investigation LPA reviewed documents including the Grace Retirement Village Infection Control. Per Infection Control standard precautions include a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status. Per Infection Control these practices include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with AD Song, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 5 of 8
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
04/23/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240423112858

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:
04/22/2025
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Michelle Song-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident files do not contain all required information
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on April 23, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Michelle Song. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that Resident files do not contain all required information. Regarding the allegation the following was revealed: During the course of the interviews one of fourteenth individuals interview confirmed the allegation. During the course of the interviews with Residents, Resident 1 (R1) reported that the resident files should be okay. During the course of the interviews with Staff, Staff 1 (S1) reported that she does not know if the resident files contain all required information since it is the Administrator's duties. During the course of the investigation LPA reviewed the resident files for R1-R5. The files for R1-R5 included the Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights and Grace Retirement Village Admission Agreement.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 6 of 8
Control Number 22-AS-20240423112858
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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Per California Code of Regulations under Resident Records section 87506 it states: Each resident’s record shall contain at least the following information: Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources.

Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: Resident files do not contain all required information is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with AD Song and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
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)
Page: 7 of 8
Control Number 22-AS-20240423112858
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: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2025
Section Cited
CCR
87506(a)(b)
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Resident Records 87506(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the
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Licensee to update the Resident Records and email LPA proof by POC due date. A written statement will be submitted by the Licensee/Administrator that the he/she understood the regulation and will comply.
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following information. This requirement was not met as evidence by: files for R1-R5 only had the Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights and Admission Agreement.
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Each resident’s record shall contain at least the following information: Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8