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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 09/24/2025
Date Signed: 09/24/2025 11:49:43 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
06/20/2022 and conducted by Evaluator Celine Rodriguez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220620170336
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:
09/24/2025
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Facility Administrator - Ngoc "Nick" MaiTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff do not ensure resident's special diet is followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Ngoc "Nick" Mai.

It was alleged that staff do not ensure resident's special diet is followed. 2 out of 2 resident interviews and 1 out of 1 staff interview did not corroborate with the allegation. Per resident 1 's (R1) physician report, R1 is to be on a puree diet. R1 is the only resident at the facility who has a special diet, while the remaining 4 residents do not require special dietary orders. Upon entrance of the facility, LPA observed staff preparing R1's breakfast by pureéing it with a blender. During the tour of the facility, LPA observed that the facility is equipped with multiple blenders and supplies to ensure that R1's special dietary needs are followed.

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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-20220620170336
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: 09/24/2025
NARRATIVE
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Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA 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, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with AD Mai.

A copy of this report was provided and explained.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2