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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 04/14/2025
Date Signed: 04/14/2025 01:47:19 PM

Unfounded


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
07/11/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240711144555
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 95DATE:
04/14/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Michelle SongTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Staff member did not treat residents with dignity and respect
INVESTIGATION FINDINGS:
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13
Regarding the allegation: Staff member did not treat residents with dignity and respect

10 of 11 individuals denied the compliant allegation. During the investigation it was discovered the incident involving the police arriving at the facility was not caused or related to (S3). It is unclear exactly who the police were called on, but the police were not called because of a facility staff member or a facility resident. The police were called on someone visiting one of the residents or attempting to visit one of the residents.

According to Staff 2 (S2) someone came to visit Resident 1 (R1) and the person arrived with an attitude. S2 explained that when the person was asked to sign in, the person refused, and the person was saying a lot of “F” words. S2 said the person was yelling and yelling, so S2 called 911 twice. S2 said R1’s family was also contacted. When a family member of R1 arrived at the facility, the family member of R1 had the person who was attempted to visit, arrested.

Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
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-20240711144555
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: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 04/14/2025
NARRATIVE
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 Witness 2 (W2) claims the police were called to the facility because a visitor showed up (to the facility) and was not willing to do what they (staff) wanted them to do. The person thought they could do whatever they wanted to, according to the witness. W2 claims, the person who arrived at the facility and was being disruptive, struck (hit) one of the workers (S3) before eventually being arrested.

According to S3, who was present when the person arrived at the facility, said the person grabbed S3’s chest area and S3 ran to a resident’s room because S3 was scared. According to S2, the family member/POA for R1 was contacted by facility staff, arrived at the facility, and had the person who was being disruptive arrested.

Based on the information gathered during through interview, observation, and document review, the following allegation: Staff member did not treat residents with dignity and respect, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2