306005470-9-26-2023-22-AS-AORZ-CW5QJ6-20230929121212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005470
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:46:51 PM

Unsubstantiated

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
08/11/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230811164351

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:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	12:52 PM
MET WITH:	Nick Mai		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff hit resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff, witness and residents as well as reviewed and obtained pertinent documentation such as staff schedule and physician report.
Regarding the allegation that staff hit resident in care, the investigation revealed the following: LPA interviewed staff, residents and witnesses during the course of the investigation. Three out of three residents deny any verbal or physical abuse at the facility. All three residents verbalized satisfaction and safety at the facility. Residents all appeared clean, well taken care of and happy. On both visits, LPA observed residents engaged in activities and enjoying themselves. Two out of two staff and witness deny any verbal or physical abuse occurring in the facility. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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