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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 06/11/2025
Date Signed: 06/11/2025 09:37:48 AM

Document Has Been Signed on 06/11/2025 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR/
DIRECTOR:		MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 340CENSUS: 93DATE:
06/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:37 AM
MET WITH:Michelle SongTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701 and while reviewing the facility’s insurance policy. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection.

During today’s inspection, LPA inspected the facility and observed the following: while the facility was licensed with a single memory care on the first floor, LPA observed that an additional memory care has been set up on the third floor with functional delayed egress doors. Per interviews with AD and Licensee (LE) Erik Doan, the facility began keeping residents with memory issues in this third floor memory care early in 2025 in order to provide closer supervision and to separate them from the ambulatory memory care residents in the first floor memory care. AD and LE provided conflicting information regarding whether these residents needed to be in a memory care. However, the facility did not notify LPA of this new memory care with delayed egress, request an update to its plan of operation, or receive approval for this change and LPA first learned of this new memory care after observing it months after it was created. During the inspection, the maintenance manager attempted the deactivate the delayed egress doors but was unsuccessful. LE stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care. LPA advised LE on the process for properly requesting a new memory care for approval if LE is interested in adding a third floor memory care.

CONTINUED
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/11/2025
NARRATIVE
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On April 23, 2025, Department staff requested a copy of the facility’s insurance policy. On April 23, 2025, LE submitted to LPA the facility’s insurance certificate and binder for the period November 12, 2024 to November 12, 2025 for the insurance policy ending in 8506. However, review of this insurance binder revealed that the facility’s insurance does not provide the required coverage of “injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees,” including because the insurance contains sub-limits of one hundred thousand dollars ($100,000) per occurrence and three hundred thousand dollars ($300,000) in the total annual aggregate for claims relating to elopement, sexual abuse, and pressure injury, which are typical injuries and issues seen in this facility type. Based on the information obtained, the facility currently does not have insurance that is compliant with Title 22 Regulations.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 09:37 AM - It Cannot Be Edited


Created By: Sean Haddad On 06/11/2025 at 09:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2025
Section Cited
CCR
87208(a)

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87208 Plan of Operation (a) … Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… This requirement was not met as evidenced by:
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Licensee stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care and submit proof to LPA by POC due date.
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Based on interviews and documents, the licensee did not notify LPA or obtain approval for a new memory care on the third floor not included in the facility’s plan of operation when the facility was licensed, which poses an immediate safety and personal rights risk to persons in care.
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Type A
06/12/2025
Section Cited
HSC1569.605

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… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by:
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Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.
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Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Sean Haddad
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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