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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 12/23/2025
Date Signed: 12/23/2025 03:12:47 PM

Unsubstantiated


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
11/29/2021 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211129125638
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: 5DATE:
12/23/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ngoc Mai TIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not follow a resident's dietary needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the complaint allegation listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. The complaint investigation consisted of interviews with facility staff, a witnesses, a resident family member, and document review.

During interviews, 5 of 5 individuals were not able to provide any corroborating evidence or information to support the complaint allegation. According to Staff 1 (S1), Resident 1 (R1) passed away at UCI Medical Center. S1 explained, R1 was sent to the hospital due to a cough and after consulting with the residents family. R1 passed away at the hospital about a week later. S1 talked a little about R1’s diagnoses and explained that everyone including the nurses at CalOptima knew R1 was in poor health.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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 2
Control Number 22-AS-20211129125638
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: GRACES HOME
FACILITY NUMBER: 306005470
VISIT DATE: 12/23/2025
NARRATIVE
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According to W1, there were no concerns about the care of R1 at the facility. W1 stated, the facility did a great job. W1 explained, R1’s spouse was present and would go to the facility to assist with R1’s feeding. W1 denied R1 was on a special diet that was related to the residents health condition. W1 says R1 was on a special diet due to the residents age and for no other reason. W1 denied R1 was on any dietary restrictions and was told to avoid foods that are spicy or salty only. W1 says R1 was not restricted to only eating certain foods.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the 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, the allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2