<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:10:26 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
04/21/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220421083332
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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ngoc "Nick" MaiTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Inadequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Edward Tapia and Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival LPAs met with Staff He Le. Administrator (AD) Nick Mai was contacted and arrived at approximately 9:00 am. A tour of the physical plant was conducted. There were 3 residents present and the following was observed:

Staff He Le was present by himself and stated that he is the only staff working at the facility. Records were reviewed and interviews were conducted. Resident 1 and 2 present were non-ambulatory, had limited mobility and needed assistance with all ADL's due to their cognitive ability. Resident 3 did not have required paperwork present and LPAs noted that he needed assistance. Based upon observation, a review of records and interviews, the preponderance of evidence standard has been met and this allegation is substantiated.

See LIC9099D for cited deficiencies. An exit interview was conducted and a copy of this report and appeal rights were given to AD Nick Mai
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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-20220421083332
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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Personel Requirements-General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by;
1
2
3
4
5
6
7
Licensee/Adminstrator agrees to hire adequate staff to meet the needs of all residents and to have more than 1 staff present at all times.
LIcensee/Adminstrator will provide proof of adequate staffing and proof of understanding via written certification and an LIC 500 form by 4/27/22
8
9
10
11
12
13
14
Records reviewed and interviews conducted disclosed that residents present during the visit were non-ambulatory, had limited mobility and needed assistance with all ADL's due to their cognitive ability. LPAs observed only 1 staff present during the visit.
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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
04/21/2022 and conducted by Evaluator Michelle Reed
COMPLAINT CONTROL NUMBER: 22-AS-20220421083332

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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ngoc "Nick" MaiTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Food services are inadequate.
Resident's bathing needs are not being met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Edward Tapia and Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival LPAs met with Staff He Le. Administrator (AD) Nick Mai was contacted and arrived at approximately 9:00 am. Records were reviewed and interviews were conducted. LPAs also inspected the food supply. The following was observed:

Licensee had 7 days of non-perishable food and 2 days of perishable food. Licensee states he will be going shopping today and will buy more fresh fruit and vegetables. Lunch will be rice and fish and beef soup. Dinner will be chicken, rice and tofu. Interview with Adminstrator and staff disclosed that residents are bathed 3 times a week unless the resident refuses. Residents could not be interviewed due to their cognitive impairment and language barrier.

The allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report and appeal rights were given.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 3