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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 11/14/2025
Date Signed: 11/14/2025 04:11:24 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
11/10/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251110164147
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: 95DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Michelle SongTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility staff did not properly document resident medications
Facility staff did not dispose of expired medications
Facility staff did not ensure resident wound care was properly documented
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 allegations. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegations.

The investigation into the allegations that facility staff did not properly document resident medications, facility staff did not dispose of expired medications, and facility staff did not ensure resident wound care was properly documented revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, the facility’s centrally stored medication records, the facility’s medication administration records, and Resident #1’s (R1) hospice medical records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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-20251110164147
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: 11/14/2025
NARRATIVE
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Regarding the allegation that facility staff did not properly document resident medications: it was alleged that the facility did not document R1’s Morphine and Lorazepam, Resident #2’s (R2) Morphine and Lorazepam, and Resident #3’s (R3) Morphine. LPA inspected the facility, conducted health and safety checks on R1, R2, and R3, and observed no health and safety issues. LPA interviewed AD, who admitted the allegation, stating that these residents were on hospice and had these medications delivered to the facility upon being admitted to hospice but the centrally stored medication records and medication administration records for these residents did not include these medications despite AD’s multiple attempts to get the hospice company and pharmacy to include these medications on these documents. LPA reviewed the centrally stored medication records and medication administration records for R1, R2, and R3 and confirmed that these medications were not included on these documents when the medications were delivered to the facility and in the case of R1 and R2 were not included on these documents for multiple months.

Regarding the allegation that facility staff did not dispose of expired medications: it was alleged that on October 30, 2025, bottles of expired antacids and anti-gas medications were found in the medication room with expiration dates of August 2025, multiple expired suppositories were found in the medication room refrigerator with expiration dates of July 2025, and AD and the medication technician were notified and stated they would destroy these expired medications and reorder new ones. LPA interviewed AD who admitted the allegation, stating that expired medications were found in the facility’s medication room and that after being made aware of the expired medications, facility staff destroyed them following the facility’s protocol. AD stated they did not believe these medications were given to residents after they expired.

Regarding the allegation that facility staff did not ensure resident wound care was properly documented: it was alleged that R1 did not have documentation of the wound care for R1’s stage 1 pressure wound. LPA reviewed R1’s hospice medical records which indicate that on October 24, 2025, R1’s doctor diagnosed R1 with a stage 1 pressure ulcer and gave an order for wound care. LPA interviewed AD who admitted the allegation, stating that the facility was unaware that R1 had a wound or was receiving wound care and the facility did not have documentation for the wound care provided by R1’s hospice company as of October 30, 2025, but that the facility requested and received the wound care records at a later date. AD stated that apart from the wound care R1 received from their hospice care team, R1 received the facility’s standard repositioning care from the facility’s own staff, but that this care was not documented either.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20251110164147
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: 11/14/2025
NARRATIVE
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LPA reviewed R1’s hospice medical records which shows that R1 received wound care from their hospice care team, but this documentation was not obtained by the facility until weeks after the wound care began and is still incomplete for the time period between October 24, 2025 and November 10, 2025.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. 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: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20251110164147
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: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
87633(k)
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87633 Hospice Care of Terminally Ill Residents … (k) The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility. This requirement was not met as evidenced by:
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The licensee stated they will ensure the centrally stored medication records and medication administration records for all residents contain all of their medications and submit proof to LPA by POC due date.
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Based on documents and admission, the licensee did not ensure all the medications of R1, R2, and R3 were documented on their centrally stored medication records and medication administration records, which poses a potential health risk to persons in care.
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Type B
11/28/2025
Section Cited
CCR
87465(i)
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87465 Incidental Medical and Dental Care (i) Prescription medications which are not… returned to the issuing pharmacy … which are otherwise to be disposed of shall be destroyed in the facility…This requirement was not met as evidenced by:
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The licensee stated they will submit a medication destruction record documenting the destruction of the expired medications to LPA by POC due date.
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Based on admission, the licensee did not timely dispose of or destroy expired medications, which poses a potential health risk to 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20251110164147
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: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
87631(a)(3)(B)
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87631 Healing Wounds (a)… (3) Residents with a stage one or two pressure injury… (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by:
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The licensee stated they will create a protocol for reviewing hospice files for new diagnoses and treatment plans to ensure all requirements are met and submit proof to LPA by POC due date.
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Based on admission and documents, the licensee did not ensure R1’s wound care from their hospice care team, or the repositioning care of the facility’s own staff, was documented in R1’s file, which poses a potential health risk to 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5