306005470-4-29-2024-22-AS-LMOA-D4TTDK-20240430143824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 04/29/2024
Date Signed: 04/29/2024 09:20:46 AM

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
09/01/2020 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200901153600

FACILITY NAME:	GRACES HOME		FACILITY NUMBER:	306005470
ADMINISTRATOR:	MAI, NGOC		FACILITY TYPE:	740
ADDRESS:	2152 S JETTY DR		TELEPHONE:	(714) 553-1166
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 3	DATE:	04/29/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Ngoc Mai- Licensee/Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Resident left in soiled diapers on multiple occassions.
Resident left in soiled diaper for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA met with Licensee/Administrator Ngoc Mai and was advised of the visit and the allegations.

On September 1, 2020, the Department received the complaint. The complaint investigation was initiated by LPA Ruth Martinez on September 9, 2020, via a tele-visit due to Coronavirus 2019 precautionary measures. During the tele-visit, LPA Martinez conducted an interview with staff and obtained pertinent records via email. On April 24, 2024, LPA Cho made an unannounced subsequent visit to continue the investigation from 9:20am-11:10am. LPA Cho conducted interviews with the staff and residents; however, interviews were terminated prematurely for three out of the three residents due to language barriers and/or their refusal to participate. Additional interviews were conducted via telephone with the exception of Resident #1 (R1). The following was revealed during the course of the investigation:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200901153600

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: 04/29/2024

NARRATIVE

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It is alleged that the resident was left in soiled diapers on multiple occasions. Three out of the three staff indicated that R1 was provided incontinent care such as diaper changes. All staff expressed that R1’s diaper was changed as needed and at their request by calling their name or using the buzzer. R1 was cognitively “sharp” and was able to express their needs which aligned with the Physician’s Report dated May 14, 2020. The family member who also corroborated with the statement was unable to recall details to R1’s care.

It is alleged that the resident was left in soiled diaper for an extended period of time. Three out of the three staff denied the allegation and the family member was unable to provide further information.

Therefore, based on the interviews and the record review, 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 following allegations: Resident was left in soiled diapers on multiple occasions and Resident was left in soiled diaper for an extended period of time are deemed UNSUBSTANTIATED.

An exit interview was conducted with Licensee/Administrator Ngoc Mai, and a copy of this report including the LIC9099C and the LIC811 were provided at exit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC9099 (FAS) - (06/04)

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