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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201903
Report Date: 09/19/2023
Date Signed: 09/19/2023 09:55:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230811090951
FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198201903
ADMINISTRATOR:AARON, RUTHFACILITY TYPE:
735
ADDRESS:2417 WEST 154TH STREETTELEPHONE:
(310) 537-2018
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:6CENSUS: 3DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Ruth AaronTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff files are incomplete.
Resident files are incomplete.
Facility staff failed to propery administer medications as prescribed.
INVESTIGATION FINDINGS:
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On 08/17/23, Licensing Program Analyst (LPA), Perry Scott conducted a 10-day complaint investigation visit at the facility listed above. LPA Scott met with Director, Ruth Aaron, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/17/23, the investigation consisted of the following:

During today's visit LPA toured the facility inside and out. LPA interviewed Director, Ruth Aaron and obtained the following documents from the facility: staff and client rosters, ID/Emergency information, Physicians reports, staff training, staff certifications, and administrator certificate.

The investigation revealed the following: Staff files are incomplete.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 6
Control Number 11-AS-20230811090951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201903
VISIT DATE: 09/19/2023
NARRATIVE
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On 08/17/23, LPA reviewed all staff files and found that the facility was in compliance with title 22 regulations except for the following: S2 CPR training certificate missing, S3 DSP I & II certificates and CPR were missing; additionally, the facility did not have a first aid manual on site.

Based on interviews, observations, and records reviewed there is sufficient evidence to support the allegation: Staff files are incomplete. The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are cited on the attached LIC 9099D.

Allegation: Resident files are incomplete.

On 08/17/23, LPA reviewed all client files and found that they were complete except for: C1 is missing a consent form. C1 and C2 both have current physical exams and optometrist reports.

Based on interviews and records reviewed there is sufficient evidence to support the allegation: Resident files are incomplete. The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are cited on the attached LIC 9099D.

Allegation: Facility staff failed to properly administer medications as prescribed.

On 08/17/23, LPA reviewed the medication administration records, along with the Special Incident Reports, and found the allegation to be Substantiated, the facility did fail to administer medications as prescribed. There were medication errors for C1 and C2 on 03/17/23.

Based on records reviewed there is sufficient evidence to support the allegation: Facility staff failed to properly administer medications as prescribed. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are cited on the attached LIC 9099D.

Deficiencies were cited.

An exit interview was conducted with Vice President, Christopher Aaron, and a hard copy of a LIC 9099 and LIC 9099D, and a plan of corrections was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20230811090951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201903
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
80075(B)
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80075(B) Health Related Services. Staff training shall be documented in facility personnel files. Facility shall have a first aid manual on-site. The requirement is not met as evidenced by:
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The administrator will ensure that S2 has an updated CPR training certificate on file; S3 has a DSP I & II certificate and CPR certifiicate on file; & the facility will have an up to date first aid manual on site. The facility will email documentation of all required documents by the POC due date of 10/10/23 to perry.scott@dss.ca.gov.
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Based on record review- LPA did not observe in service trainings for S2 CPR Training Certificate, and S3 DSP I and II certificates and CPR certificates on file in the facility.
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Type B
10/10/2023
Section Cited
CCR
80070(a)
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80070(a) Client Records
The Administrator shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:
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Administrator will ensure that Consent for Treatment forms are signed by Consumer or Consumer’s responsible party for C2, and email documentation to perry.scott@dss.ca.gov by due date of…
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Based on record review, LPA observed that a medical consent form was missing for C2.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230811090951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201903
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
80075(b)(5)(B)
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80075(b)(5)(B) Health Related Services
Medications shall be given according to the physician’s directions. This requirement is not met as evidenced by:
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The Administrator will ensure that all staff take a medication training course and will fax a copy of the agenda and sign in sheet for all staff by the POC due date of 10/10/23 and email it to LPA at perry.scott@dss.ca.gov.
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Based on record review, LPA observed medication errors for C1 & C2 dated 03/17/23.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230811090951

FACILITY NAME:GRACE CARE CORPORATIONFACILITY NUMBER:
198201903
ADMINISTRATOR:AARON, RUTHFACILITY TYPE:
735
ADDRESS:2417 WEST 154TH STREETTELEPHONE:
(310) 537-2018
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY:6CENSUS: 3DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Ruth AaronTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
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9
Facility staff are sleeping in the garage.
Facility staff are not properly trained.
Facility Administrator does not have an active Administrator certificate.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/17/23, Licensing Program Analyst (LPA), Perry Scott conducted a 10-day complaint investigation visit at the facility listed above. LPA Scott met with Director, Ruth Aaron, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/17/23, the investigation consisted of the following:

During today's visit LPA toured the facility inside and out. LPA interviewed Director, Ruth Aaron and obtained the following documents from the facility: staff and client rosters, ID/Emergency information, Physicians reports, staff training, staff certifications, and administrator certificate.

The investigation revealed the following: Allegation Facility staff are sleeping in the garage.

Report continued on LIC9099-A
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 6
Control Number 11-AS-20230811090951
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRACE CARE CORPORATION
FACILITY NUMBER: 198201903
VISIT DATE: 09/19/2023
NARRATIVE
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On 08/17/23, LPA interviewed S1 about the allegation. S1 denied the allegation. LPA and S1 toured the garage. LPA observed that in its present state, it was determined that no one was sleeping in the garage. LPA observed dirt and debris throughout the garage, and it did not contain any accommodations for anyone to sleep or congregate for a rest period. LPA observed that it looked like an unused garage.

Based on observation and an interview, there is insufficient evidence to support the allegation: Facility staff are sleeping in the garage. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility staff are not properly trained.

On 08/17/23, LPA reviewed all staff files and found that all staff has had on-going training in: HCBS Final Rule, SCLARC client rights, Direct Care Staff On-site Orientation, PRN Medications log, Mitigations Log, Mitigation Plan, Defining Special Incidents, and Reporting Agencies (SIR) in-service training.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation: Facility staff are not properly trained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility Administrator does not have an active Administrator certificate.

On 08/17/23, LPA reviewed the administrators’ certificate and found that it was active and expires on 12/03/2023, for S4.

Based on records reviewed, there is insufficient evidence to support the Facility Administrator does not have an active Administrator certificate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted with Vice President, Christopher Aaron, and a hard copy of a LIC 9099A was given.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6