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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:19:11 PM

Substantiated


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
02/03/2023 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20230203140953
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:
09/26/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Ngoc "Nick" MaiTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not adequately supervise resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegations mentioned above. LPA met with Caregiver (CG) staff Quy "Anna" Mai while administrator was not present.

It was alleged that facility staff did not adequately supervise resident while in care. During the investigation LPA interviewed staff and attempted to interview resident; obtained staff and resident roster, checked resident file, admission agreement, level of care assessment, discharge paperwork. The investigation determined the following:

During investigation, LPA obtain and reviewed Resident 1’s (R1) physician’s report dated 02/17/2023 showing that R1’s primary diagnosis is dementia. In section 14, “Mental Condition,” sub-section k “able to leave facility unassisted” the doctor marked “NO.” R1 is unable to leave the facility without a staff assisting them. On the evening of 2/01/23, R1 left the facility unassisted and was missing until the following morning. (Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20230203140953
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87464(f)(1)
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Basic Services ... Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced
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Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.
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Based on interview and review of documents licensee failed to supervise R1 in which they left the facility unassisted and ended up at emergency at hospital.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230203140953
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: 09/26/2024
NARRATIVE
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Per interview with AD Mai allows R1 to sit outside on the facility front porch unsupervised. AD stated he leaves the front door unlock for R1. AD explained that R1 usually comes back from outside and goes in their room and closes their door. The night of the incident, AD Mai check and saw a blanket covering R1’s pillow and thought R1 was in bed. AD stated he didn’t hear R1 leave. AD reported the door alarm was turned off because it irritates R1. AD Mai was not aware that R1 was missing until in the morning where he usually wakes up R1 for breakfast. Upon realizing R1 was missing, AD checked the facility and surrounding neighborhood and notified police & R1’s responsible party. AD does not recall notifying CCLD about R1's elopement. LPA did not find any SIRs from the facility around that time period of the incident.

R1 was brought to UCI Medical Center via paramedics after a syncope and collapse. After a series of tests, R1 was diagnosed with facial trauma to their forehead and nose. Per hospital discharge paperwork dated 2/2/23, R1’s head CT scan did not show any signs of acute intercranial hemorrhage, herniation or hydrocephalus. AD Mai was not aware that R1 was brought to the hospital upon admission. AD Mai was contacted by hospital staff upon finding his business card in R1’s pocket.

Hospital records note R1 did not recall the event and was unclear how they came to be in Orange County. LPA attempted to interview R1 who refused to speak with LPA.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility staff did not adequately supervise resident while in care 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 with Caregiver Quy "Anna" Mai and Ngoc “Nick” Mai over the phone and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3