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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005470
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:32:12 PM


Document Has Been Signed on 04/24/2023 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: 4DATE:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Ngoc "Nick" Mai, Licensee/AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number: 22-AS-20221110131242. LPA Quiroz was greeted and granted entry into the facility by Administrator Ngoc "Nick" Mai and explained the reason for the visit.
During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation.
The investigation found the following:
Hospital records confirm that R1’s responsible party informed hospital staff that R1 was not brought in by their caregiver due to caregiver having two other people to take care of. Facility was cited for lack of staffing on 2/07/2023 during a Case Management inspection by the Department. As of today’s date, the Plan of Correction has not been met.
When interviewed regarding the fall, the Administrator reported they did not submit a written unusual incident report (UIR) to the Licensing Department as they didn’t think it was necessary as they believed R1 to be improving. The Administrator further reported they did not contact 9-1-1 as they believed the family would handle R1’s medical needs and that by contacting R1’s family, the Administrator believed he had met his Administrator duties.
Following R1’s fall it was reported R1 was no longer able to walk. Hospital records from 11/09/2022 confirm R1 sustained a closed hip fracture. Despite the change in condition, no updated reappraisal was observed on file.
In addition to the above noted incident, hospital records note R1 was hospitalized on 8/26/22 due to being hypotensive. While there, blood glucose levels for R1 were noted to be 244.
The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8. (SEE LIC 809-D Pages)
An exit interview was conducted with Administrator and a copy of this report, confidential names list and appeal rights was provided at the time of exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/24/2023 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited

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87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: Following R1’s fall the facility failed to CONTINUED...
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L/AD Mai will read and submit proof of understanding for CCR 8746: Reappraisals and submit proof of undetrstanding to CCLD by POC Deadline of 4/28/2023.
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CONTINUE...complete a reappraisal despite R1 being unable to walk. R1 was able to walk with assistance prior to fall. This poses a potential risk to residents in care.
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Type B
04/28/2023
Section Cited

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87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED...
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L/AD Mai will read and submit proof of understanding for CCR 87211: Reporting Requirements and submit proof of undetrstanding to CCLD by POC Deadline of 4/28/2023.
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health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to the Licensing agency regarding R1’s unwitnessed fall in October of 2022 or hospitalization on 8/26/22. This poses a potential risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/24/2023 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited

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87411(a) Personnel 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 was not met as evidence by: The facility failed CONTINUED...
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L/AD Mai will read and submit proof of understanding for CCR 87411: Personnel Requirements and submit proof of undetrstanding to CCLD by POC Deadline of 4/25/2023.
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CONTINUE...to seek immediate medical attention for R1 in part due to the caregiver needing to care for two other residents. The facility lacked sufficient staffing to be able to meet the resident’s need for immediate medical attention. This poses an immediate risk to residents in care.
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Type A
04/25/2023
Section Cited

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87405(d) Administrator- Qualification and Duties. The administrator shall have the qualifications specified…Knowledge of the requirements for providing care and supervision … and ability to conform to the applicable laws, rules and regulations. This CONTINUED...
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L/AD Mai will read and submit proof of understanding for CCR 87305: Administrator Qualification and Duties and submit proof of undetrstanding to CCLD by POC Deadline of 4/25/2023.
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CONTINUE...requirement was not met as evidence by: Administrator failed to ensure the facility was properly staffed; failed to submit necessary written reports to licensing and failed to seek appropriate medical attention for R1. This poses an immediate risk to residents in care.

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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3