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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/11/2025
Date Signed: 09/11/2025 04:00:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/10/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250910130607
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 97DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Michelle SongTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure the facility is free from mold
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegation.

The investigation into the allegation that staff do not ensure the facility is free from mold revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and photographs.

CONTINUED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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 3
Control Number 22-AS-20250910130607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/11/2025
NARRATIVE
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It was alleged that the facility has visible mold in the kitchen where staff prepare food. LPA reviewed photographs showing black mold on the ventilation pipes in the kitchen with condensation dripping down onto food prep areas. LPA inspected the kitchen and observed that the exterior of the ventilation pipes had been partially cleaned, but that some of the mold was still present on the pipes, and also observed staff conducting a deep cleaning of the kitchen. LPA observed additional black mold behind a short chest freezer in the kitchen that had not been cleaned and as well as additional mold near the vents in the first floor memory care common area and second floor chapel room. LPA interviewed AD who stated the facility is currently deep cleaning the kitchen, has taken alternative measures to ensure residents are receiving safe and healthy food, and that the facility has already called a professional to clean the mold and ensure the facility is mold free. While the facility is now taking steps to address the mold, the information obtained corroborated that the facility did not timely address the mold as it grew throughout the facility, including the kitchen.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250910130607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by:
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Licensee stated that they will clean, disinfect, and have the affected areas professionally confirmed to be mold free and submit proof to LPA by POC due date.
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Based on observation and interview, the licensee did not ensure the kitchen, first floor memory care, and second floor chapel were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.
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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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3