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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 11/19/2025
Date Signed: 11/19/2025 04:45:52 PM

Document Has Been Signed on 11/19/2025 04:45 PM - 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: 95DATE:
11/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Michelle SongTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on November 19, 2025 regarding Resident #1 (R1). LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on November 19, 2025, on November 2, 2025, R1 left the facility without staff noticing around 6AM, was found by the police miles away, and was sent to the hospital. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated February 6, 2025, which indicates R1 has mild cognitive impairment but can leave the facility unassisted. Per AD, R1 did not have dementia, but lived in the memory care unit due to psychiatric issues. Per AD, R1 is still at the hospital, R1 escaped by using a chair to jump a fence in the memory care courtyard and did not trigger the facility’s delayed egress alarms, and R1 was hospitalized after fighting with police when they were found on November 2, 2025 but AD is unaware of any injuries to R1. LPA reviewed R1’s involuntary evaluation application dated October 30, 2025, which indicates that prior to R1’s elopement on November 2, 2025, R1 was detained by Garden Grove Police Department during another elopement on October 30, 2025, due to being gravely disabled, being observed walking in street traffic due to their dementia. Per facility staff, R1 leaving on October 30, 2025, was also not noticed by staff and no delayed egress alarms were triggered and it is believed R1 jumped another fence. Per facility staff, on October 30, 2025, R1 was hospitalized but was cleared to go back to the facility the same day or the next day by the doctor at the hospital, facility staff protested R1’s return to the facility to the doctor at the hospital, but R1 was still returned to the facility and the doctor said they would send new medications to R1’s pharmacy.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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: 11/19/2025
NARRATIVE
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Per AD and facility staff, the facility did not have a chance to reassess R1 as they eloped again in the next few days on November 2, 2025, and it is unclear if the new medications ever arrived. Facility staff stated they put R1 on 30-minute checks after their first elopement, but there are no logs available, and the checks provided by facility staff were insufficient to meet R1’s care and supervision needs. Based on the information obtained, the facility did not put in place sufficient measures to address R1’s elopement even after knowing of their previous elopement a few days earlier. LPA inspected the delayed egress doors in the memory care unit and confirmed they work properly. LPA reviewed the incident reports received in the OCRO and noted that R1’s elopement on October 30, 2025 was not reported. Based on the information obtained 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: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2025 04:45 PM - It Cannot Be Edited


Created By: Sean Haddad On 11/19/2025 at 04:38 PM
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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2025
Section Cited
CCR
87464(f)(1)

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87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received care and supervision to meet their needs
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Licensee stated they will retrain staff on elopements and submit proof to LPA by POC due date.
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 resulting in a second elopement in less than week, an altercation with police, and hospitalization, which poses an immediate safety risk to persons in care.
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Type B
11/26/2025
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a) … (1) ... (D) Any incident which threatens the welfare, safety or health … unexplained absence of any resident. This requirement was not met as evidenced by:
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Licensee stated they will retrain staff on reporting requirements and submit proof to LPA by POC due date.
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Based on interview and documents, the licensee did not report R1’s elopement on October 30, 2025, to the OCRO, which poses a potential safety 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Sean Haddad
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


LIC809 (FAS) - (06/04)
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