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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/03/2026
Date Signed: 04/03/2026 10:15:30 AM

Substantiated


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
03/17/2026 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260317114133
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: 86DATE:
04/03/2026
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Man ParkTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with staff Man Park and explained the reason for today’s inspection.

The investigation into the allegation that staff are mismanaging residents medication revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Michelle Song, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) IV Order dated March 13, 2026, Resident #2’s (R2) IV Order dated March 16, 2026, and Medication Administration Records.

CONTINUED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
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-20260317114133
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: 04/03/2026
NARRATIVE
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It was alleged that R1 received IV infusions with an IV bag that had a partially peeling or missing label, R2 received IV infusions with an IV bag that had another resident’s name on it, and the facility had no doctor’s orders for the IV infusions. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who admitted the allegation, stating that on March 16, 2026, R1 and R2 were administered IV infusions due to weakness and not eating, the IV infusions were ordered by the residents’ nurse practitioner verbally but a written order was not received until the nurse practitioner arrived at the facility on March 18, 2026, and that the IV bags given to these residents were from the facility’s stock and were not delivered to the facility for these residents. LPA reviewed R1’s IV Order dated March 13, 2026, and R2’s IV Order dated March 16, 2026, which per AD were written on March 18, 2026, but given verbally on March 16, 2026, and noted they are for “IV 05 ½ NS”. LPA observed six IV bags at the facility, none of which were labeled for R1 or R2. Two bags were labeled for Resident #3 (R3), who per AD is no longer a resident of the facility and moved out on October 31, 2025. All six IV bags are labeled as “Sodium Chloride 0.9% Solution”. However, the labels of the bags actually administered to R1 and R2 are no longer available. AD stated they are not knowledgeable about IV bags, but the nurse who administered them would have handled it. LPA attempted to interview the nurse that administered the IVs to R1 and R2, but was unsuccessful. LPA interviewed two staff who were unable to provide information regarding this allegation. LPA reviewed the Medication Administration Records for R1 and R2, which did not contain orders for IV infusions or document the IV infusions administered. Although the facility eventually received written doctor’s orders documenting that IV infusions were ordered for R1 and R2, R1 and R2 received IV bags that were delivered to the facility other residents and it is unknown if they received the correct IV bags as ordered by their doctor.

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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20260317114133
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: 04/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2026
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care (e) For every … medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, … and a label on the medication This requirement was not met as evidenced by:
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The licensee stated they will conduct medication training, including about this scenario, and submit proof to LPA by POC due date.
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Based on documents and admission, the licensee had a nurse administer IV bags to R1 and R2 that were not labeled as theirs and could have been a different formulation than that ordered, 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/17/2026 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260317114133

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: 86DATE:
04/03/2026
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Man ParkTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
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9
Staff are administering IV medication without a licensed professional
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
8
9
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12
13
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with staff Man Park and explained the reason for today’s inspection

The investigation into the allegation that staff are administering IV medication without a licensed professional revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Michelle Song, residents, and staff, and obtained and reviewed copies of the resident roster and staff roster.

CONTINUED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20260317114133
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: 04/03/2026
NARRATIVE
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It was alleged that Resident #1 (R1) and Resident #2 (R2) received IV infusions at the facility without staff or licensed supervision present. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation, stating that the IV infusions were administered by the facility’s on-call registered nurse. LPA interviewed two staff who were unable to provide additional information. When interviewed, R2 was unable to provide information regarding the allegation, but R1 stated a nurse administered their IV and staff stayed with them while it was in place. LPA attempted to interview the nurse who administered the IV, but was unsuccessful.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5