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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:13:18 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
11/10/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221110131242
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
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Ngoc "Nick" Mai, Licensee/AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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-Facility staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced inspection visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Administrator Ngoc "Nick" Mai and explained the reason for the inspection visit.
During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. The investigation conducted revealed the following:
Sometime in between October 09, 2022 and October 15, 2022, Administrator Ngoc “Nick” Mai discovered Resident 1 (R1) on the floor of their room around three to four AM. R1 told the Administrator they fell attempting to climb over the bed rail in an attempt to go to the bathroom. Upon finding R1, Administrator reported assessing R1 and noting no visible signs of injury; however, at the time of incident R1 reported having pain in their upper thigh/hip area. Administrator placed R1 back in their bed and went back to sleep. The following day the Administrator contacted R1’s responsible party. R1’s responsible party asked Administrator to observe R1.
CONTINUED...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
11/10/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221110131242

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
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Ggoc Mai, Licensee/AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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-Inadequate staff supervision resulting in resident sustaining a fracture
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA 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 conducted revealed the following:
Sometime in between October 09, 2022 and October 15, 2022, Administrator Ngoc “Nick” Mai discovered Resident 1 (R1) on the floor of their room around three to four AM. R1 told the Administrator they fell attempting to climb over the bed rail in an attempt to go to the bathroom. Staff interviews reported that R1 has undergarments however is able to use the bathroom with assistance. The Administrator reported he conducts status checks on R1 if they wake up during the night but reported most residents are normally sleeping. Interviews with staff report R1 has no history of climbing over the bedrails. Staff at the facility include Administrator and his two siblings.
CONTINUED...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20221110131242
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
VISIT DATE: 04/24/2023
NARRATIVE
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Although R1 did sustain an unwitnessed fall, it remains unclear if the fall was caused due to a lack of supervision on behalf of facility staff.
Based on the investigation, the allegation that Facility did not provide adequate supervision resulting in resident jumping out a window was found to be 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 confidential names list was left at the facility.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20221110131242
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: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This regulation was not met as evidence by: Resident was found on ground CONTINUED...
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L/AD Mai will read and submit proof of understanding of CCR 87465: Incidental Medical and Dental Care to CCLD by POC deadline of 4/25/2023.
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CONTINUED...following an unwitnessed fall sometime in October of 2022. Despite reporting hip pain and being unable to walk, no medical attention was sought. R1 was transferred to the hospital approximately a month later and diagnosed with a hip fracture.
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This poses an immediate risk to residents in care. $500 IMMEDIATE CIVIL PENALTY IS ASSESSED.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20221110131242
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
VISIT DATE: 04/24/2023
NARRATIVE
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CONTINUED...When Interviewed by the Department and asked why they did not have R1 transported to the hospital, R1’s responsible party stated they believed R1 to be improving and didn’t think the situation was serious despite R1’s continued inability to walk. R1’s primary care physician was not contacted nor notified of the fall at the time of incident.
During a visit to the facility on 11/09/2022, R1’s responsible party requested R1 be taken to the hospital for evaluation on their hip. R1 was taken to the hospital approximately a month after the initial fall where they were diagnosed with a displaced left hip fracture. The Administrator reported they expected that the family would handle R1’s medical needs. R1’s responsible party told hospital staff they were unable to take R1 to the hospital sooner due to being busy. Hospital records reviewed note that R1’s responsible party reported R1 was not brought in by their caregiver as the caregiver had two other people to take care of. R1’s responsible party reported to hospital staff R1 has memory difficulties and is often confused. R1’s family declined surgical intervention due to R1’s age.
R1 eloped from the hospital prior to being discharged with the assistance of their responsible party and returned to the facility against medical advice. R1’s physician report dated 7/12/2022 lists R1 as ambulatory prior to the fall. Following the fall, R1 was unable to walk and relied on a wheelchair for transportation. An interview with R1’s responsible party confirms that R1 is no longer able to ambulate following the fall.
Based on the investigation, the allegation that Facility staff did not seek medical attention for resident in a timely manner was found to be SUBSTANTIATED.
The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8.
A civil penalty is pending determination, per H&S Code Section 1569.49(f).
An exit interview was conducted with Administrator and a copy of this report, confidential names list, civil penalty, 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5