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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:57:02 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
03/08/2024 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240308085205
FACILITY NAME:GRACES HOMEFACILITY NUMBER:
306005470
ADMINISTRATOR:MAI, NGOCFACILITY TYPE:
740
ADDRESS:2152 S JETTY DRTELEPHONE:
(714) 553-1166
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 3DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ngoc Mai - Licensee/Administrator TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility failed to pay electricity bill timely
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA Mendivil was greeted and granted entry into the facility by Licensee/Administrator Ngoc Mai and explained the reason for the visit.

The department received a complaint on 03/08/2024, and LPA Mendivil conducted initial 10 day visit same day. LPA Mendivil interviewed Licensee/Administrator Ngoc Mai and obtained copies of electronic payment receipt. Regarding the allegation facility failed to pay electricity bill timely, the investigation revealed the following:
Per interview with Licensee/Administrator Mai the electricity was on auto pay and the card linked to the account had expired in October 2023. Licensee Mai stated that he was not aware as he does not often check his emails linked to the electricity account and did not receive anything in the mail or calls regarding the late payments. On 03/01/2024 a door tag was left on the front door of the facility indicating a payment was due by 03/01/2024 in order to ensure electricity was not shut off.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 3
Control Number 22-AS-20240308085205
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: GRACES HOME
FACILITY NUMBER: 306005470
VISIT DATE: 03/08/2024
NARRATIVE
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Based on interview with Licensee Mai he stated that a partial payment was made on 03/01/2024 and the remaining balance was paid on 03/08/2024. LPA Mendivil received a copy of receipt of both payments from 03/01/2024 and 03/08/2024 while at the facility. It was confirmed by Anaheim Public Utilities if the balance was paid then there would not be a disruption in service.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility failed to pay electricity bill timely is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240308085205
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: GRACES HOME
FACILITY NUMBER: 306005470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2024
Section Cited
CCR
87205(a)
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(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Licensee has since paid the remaining balance of the electricity bill. Licensee has setup a auto pay with updated credit card to avoid rejected payments in the furture.
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This requirement was not met as evidence by faciltiy received a notice to pay electricity bill or face a disruption in service. This poses an immediate health and safety risks 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3