198602067-1-26-2023-28-AS-RORN-CNTSBZ-20230207124446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602067
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:27:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220120084056

FACILITY NAME:	HOUSE OF GRACE LLC		FACILITY NUMBER:	198602067
ADMINISTRATOR:	MICHELLE AGUIRRE		FACILITY TYPE:	740
ADDRESS:	618 RIDGEFIELD DRIVE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Michelle Aguirre		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff not allowing Long Term Care Ombudsman entry into the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Administrator Michelle Aguirre and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 1/21/22, LPA conducted interviews with Administrator Michelle Aguirre and Rebecca Sinclair. LPA collected copies of Staff and Resident Rosters. LPA conducted a tour of facility kitchen and observed food supply which was adequate at the time of visit. LPA observed an ample supply of food in refrigerator and non perishable food in kitchen cabinets. There was also an ample amount of fruits and vegetables. LPA also collected copy of facility menu and visitation guidelines/ procedures. On 2/16/22, LPA conducted a telephone interview with Wise & Healthy Aging, Long Term Care

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 8

Control Number 28-AS-20220120084056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 01/26/2023

NARRATIVE

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Ombudsman (LTCO) Staff 1 and received a copy of a document mailed to facility administrator from LTCO dated 1/25/22. On 1/26/23, LPA conducted interviews with Staff 1-2 (S1-2), Residents 1-5 (R1-5) and conducted telephone interviews with R1 Family Member (R1 FM), R2 FM 1-2, R3 FM, and R5 FM. LPA attempted a phone call to R4 FM but did not receive a call back. LPA additionally collected copies of Staff Roster and visitation logs. LPA reviewed 5 Resident files.

Investigation revealed the following: Regarding allegation, Staff not allowing Long Term Care Ombudsman entry into the facility, it is alleged that the facility administrator/ facility staff are not allowing LTCO staff to enter the facility. Administrator/ and or facility staff allegedly denied entry/ access into facility to LTCO staff on various dates: 2/26/21, 9/17/21, and 1/14/22. Interview with administrator revealed that she did not deny entry to LTCO staff and stated that LTCO staff were harassing her with the frequency of visits and stated that LTCO should only visit every three (3) months. Interview conducted with LTCO staff revealed that they were denied access into the facility on various dates (2/26/21, 9/17/21, and 1/14/22). LTCO staff stated that they were eventually allowed access into the facility on 2/26/21 only after being educated by LTCO Staff and Community Care Licensing (CCLD) staff about LTCO right of access to the facility. LTCO was also allowed access on 3/2/21 but on 9/17/21, LTCO staff again attempted to visit the facility, and the administrator again denied access. LTCO program had to call the administrator, and again educate administrator on LTCO right of access. Administrator stated to LTCO staff that she was not allowing entry due to the spike in COVID19 cases at the time. Administrator agreed to allow ombudsman entry. LTCO was allowed entry on 9/24/21 but again on 1/14/22, LTCO staff attempted to visit facility to conduct an investigation and was not allowed access into the facility by a facility caregiver who stated to LTCO staff that they could not allow ombudsman into the facility and they had call the administrator first. LTCO staff that they explained to the administrator that the LTCO is an essential visitor, and as such has the right to access the facility at any time. LTCO staff stated that Administrator did not give the caregiver permission to admit the LTCO staff into the facility and LTCO was not permitted access into the facility. LPA received a copy of a notice addressed to facility administrator from LTCO dated 1/25/22. The letter indicates the dates that LTCO staff was not allowed access into the facility and informs the administrator of their legal duties regarding allowing LTCO access and if the administrator continued to deny access they were in violation of federal and state law. The letter lists both federal and state laws regarding LTCO access to the facility. On 1/31/22, LPA received an email from administrator in which she states that she received the letter and also states that she spoke to CCLD staff

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Alma Gonzalez

COMPLAINT CONTROL NUMBER: 28-AS-20220120084056

FACILITY NAME:	HOUSE OF GRACE LLC		FACILITY NUMBER:	198602067
ADMINISTRATOR:	MICHELLE AGUIRRE		FACILITY TYPE:	740
ADDRESS:	618 RIDGEFIELD DRIVE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Michelle Aguirre		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Residents are not allowed to have visitors.
Facility not serving an adequate amount of food to resident's.
Resident's are not offered a variety of meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Michelle Aguirre and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 1/21/22, LPA conducted interviews with Administrator Michelle Aguirre and Rebecca Sinclair. LPA collected copies of Staff and Resident Rosters. LPA conducted a tour of facility kitchen and observed food supply which was adequate at the time of visit. LPA observed an ample supply of food in refrigerator and non perishable food in kitchen cabinets. There was also an ample amount of fruits and vegetables. LPA also collected copy of facility menu and visitation guidelines/ procedures. On 2/16/22, LPA conducted a telephone interview with Wise & Healthy Aging, Long Term Care

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 28-AS-20220120084056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 01/26/2023

NARRATIVE

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Ombudsman (LTCO) Staff 1 and received a copy of a document mailed to facility administrator from LTCO dated 1/25/22. On 1/26/23, LPA conducted interviews with Staff 1-2 (S1-2), Residents 1-5 (R1-5) and conducted telephone interviews with R1 Family Member (R1 FM), R2 FM 1-2, R3 FM, and R5 FM. LPA attempted a phone call to R4 FM but did not receive a call back. LPA additionally collected copies of Staff Roster and visitation logs. LPA reviewed 5 Resident files.

Investigation revealed the following: Regarding allegation, Residents are not allowed to have visitors, it is alleged that the facility residents are not allowed visits from family members. Interviews conducted with facility administrator and S1-2 revealed that residents are allowed to visit with family members and friends and whoever wishes to visit with residents. Staff stated that the visitors just have to go through the COVID19 screening. Interviews conducted with 1 out of 5 residents revealed that they do get visits and they do not have any concerns regarding visits. 3 residents were not able to interview as they were asleep during the visit and 1 resident did not properly answer LPA's questions regarding visits. LPA interviewed R1 FM, R2 FM 1-2, R3 FM, and R5 FM who all stated that they are able to visit with their family members and have never had any issues when they want to visit. They stated that they just have to ensure that their temperature is taken and are properly screened for COVID19. LPA reviewed visitation logs and observed that resident's visitors log in and are screened when visiting. Based on interviews conducted with facility staff, resident family members, 1 facility resident and LPA record review, there was not enough supportive evidence to concur with the reported allegation

For allegation, Facility not serving an adequate amount of food to resident's, it is alleged that there is not an adequate amount of food in the facility to offer to the residents. Interviews conducted with facility administrator and S1-2 revealed that there is an adequate amount of food at all times in the facility to offer to the residents at all times. Interviews conducted with 1 out of 5 residents revealed that they do not have concerns about the food and stated that when they want additional servings the staff will provide it to them. 3 residents were not able to interview as they were asleep during the visit and 1 resident did not properly answer LPA's questions regarding amount of food. LPA interviewed R1 FM, R2 FM 1-2, R3 FM, and R5 FM who all stated that they are satisfied with the amount of food that they have observed when visiting the facility and stated that they have not noticed a low stock of food. On 1/21/22 and 1/26/23, LPA observed an ample supply of food in refrigerator and non perishable food in kitchen cabinets. There was also an ample amount of fruits and vegetables. Based on interviews conducted with facility staff, resident family members, 1 facility

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 28-AS-20220120084056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 01/26/2023

NARRATIVE

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resident and LPA observations, there was not enough supportive evidence to concur with the reported allegation

For allegation, Resident's are not offered a variety of meals it is alleged that the facility only serves ham sandwiches for dinner. Interviews conducted with facility administrator and S1-2 revealed that residents are served a variety of meals and are not just served ham sandwiches for dinner. Staff stated that residents are served a variety of foods and stated that they are served different meals daily and if they happen to not like something that is being served they can ask for something else. Interviews conducted with 1 out of 5 residents revealed that they do not have concerns about the food and stated that they are served a variety of foods, are given additional servings if they request and are also given an alternative meal if they do not like what is being served. 3 residents were not able to interview as they were asleep during the visit and 1 resident did not properly answer LPA's questions regarding variety of meals. LPA interviewed R1 FM, R2 FM 1-2, R3 FM, and R5 FM who all stated that they are satisfied with the food service and stated that they have observed that the residents are served a variety of meals. LPA reviewed the facility menu and observed that residents are served a variety of meals. LPA also observed an ample supply of food in refrigerator and non perishable food in kitchen cabinets. There was also an ample amount of fruits and vegetables. Based on interviews conducted with facility staff, resident family members, 1 facility resident, LPA observations and record review there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Facility Staff Venus Calzado.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 28-AS-20220120084056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 01/26/2023

NARRATIVE

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regarding LTCO right to access the facility and the email also states that she allowed LTCO staff come back and do their visit. The email does not state what date.

Based on interviews conducted and LPA record review, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.

Exit interview was conducted with Facility Staff Venus Calzado. A copy of the report and appeal rights were provided to Facility Staff.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 28-AS-20220120084056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/27/2023 Section Cited HSC 1569.35(C)(2)	1 2 3 4 5 6 7	1569.35(C)(2) (2) If a local long-term care ombudsman or the State Long-Term Care Ombudsman files a complaint alleging denial of a statutory right of access to a residential care facility for the elderly under Section 9722 of the Welfare and Institutions Code, the department shall give priority to the complaint pursuant to Section 9721 of the Welfare and Institutions Code and notify the Office of the State Long-Term Care Ombudsman that an investigation has been initiated pursuant to this section.	1 2 3 4 5 6 7	Administrator to review HSC 1569.35(c)(2) and submit written Plan of Correction which states that the facility administrator and staff will ensure the facility is meeting HSC Code and allows entry to LTCO staff into the facility. Administrator to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LTCO staff was not allowed entry into the facility on various dates:(2/26/21, 9/17/21, and 1/14/22). LPA conducted interviews with facility administrator and LTCO staff and reviewed a notice that was mailed from LTCO to facility administrator which stated that administrator denied LTCO access into the facility. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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