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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:05:22 PM


Document Has Been Signed on 11/02/2023 12:05 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:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: 99DATE:
11/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Assistant Administrator - Anna JungTIME COMPLETED:
12:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit. LPA De Perio explained reason for visit, met with assistant administrator Anna Jung.

On August 22, 2023, LPA De Perio conducted a case management visit to the facility to collect random resident physician reports. Physician reports for resident 1 2, 3, 4, 5, and 6 (R1, R2, R3, R4, R5, R6) were completed and indicated that the same doctor had evaluated residents. The doctor was interviewed and presented with copies of those physician reports. The doctor verified of never seeing R1, R2, R3, R4, R5 and R6, denied of ever signing reports for residents R1, R2, R3, R4, R5, and R6 and stated that the signature had be falsified.

For this visit, citations were issued according to Title 22 California Code of Regulations.

An exit interview was conducted with assistant administrator Jung.

A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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 2


Document Has Been Signed on 11/02/2023 12:05 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: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
87207

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidence by:
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As a POC, licensee stated that no employee or officer of a licensee will make or disseminate any false or misleading statement or documents. The Licensee stated all staff will be trained on ethical conduct and truthful reporting and will submit proof to assigned LPA on or by 11/3/23.
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Based on LPA’s observation, records obtained and interviews, it was revealed that the doctor indicated on R1, R2, R3, R4, R5, and R6 physician's report denied of evaluating the residents and stated that the physician signature was falsified. This poses an immediate health and safety risk to residents in care.
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Type A
11/03/2023
Section Cited
CCR87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician...
This requirement is not met as evidence by:
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As a POC, licensee stated that all physician reports for residents will be obtained and an assessment will be conducted by the physician prior to admission. Licensee will provide an in-service to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/23.
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Based on the reviewed documents obtained, interviews conducted, and direct admission from the indicated physician on the reports, facility did not obtain a physician report and medical evaluation for R1, R2, R3, R4, R5, and R6.
This poses an immediate health and safety 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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2