306090049-3-27-2024-22-AS-SHAD-D3RVB4-20240327161656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306090049
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:17:09 PM

Document Has Been Signed on 03/27/2024 04:17 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 VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	CRYSEL SANTOS		FACILITY TYPE:	740
ADDRESS:	1100 E. WHITTIER BLVD.		TELEPHONE:	(562) 694-6515
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 111	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anna Jung, Erik Doan		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Assistant Administrator (AA) Anna Jung and discussed the purpose of the inspection. Administrator (AD) Erik Doan arrived during the inspection. LPA reviewed Infection Control requirements. At about 10:00AM, LPA and AA conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the residents. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 118 degrees in the 10 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid. At about 1:00PM, LPA reviewed 10 resident files, interviewed 10 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. CONTINUED

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 04:17 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

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, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1, which poses a potential health risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	During the inspection, the facility obtained the Physician's Report dated 02/28/24 for R1. Licensee stated that in the future they will obtain Physician's Reports before admission.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and Administrator's admission, the facility has not been conducting emergency disaster drills, which poses a potential safety risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date and will conduct them quarterly in the future.

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 04:17 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87156(a)

87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure their licensing fees were paid and has a past-due balance, which poses a potential risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	Licensee stated they will pay the fees and submit proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 03/27/2024

NARRATIVE

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During the inspection, LPA and AA observed the following: R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1; the facility has not been conducting emergency disaster drills; and the licensee did not ensure their licensing fees were paid and has a past-due balance. The facility’s staff files were not available during the inspection and a technical violation was issued.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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